Be Prepared With Answers About the New Cholesterol Guidelines

You'll hear buzz about the new cholesterol guidelines that bring back some emphasis on LDL and promote even more individualization.

Think about LDL to guide non-statin use...but ONLY for the highest-risk SECONDARY prevention patients, such as those with multiple CV events OR a single CV event plus additional CV risks (diabetes, smoking, etc).

Experts have landed on 70 mg/dL as the threshold to consider adding a non-statin...AFTER verifying adherence to statins and lifestyle changes. The change is based on more data that "lower is better" in these patients.

Continue to use a high-intensity statin (atorvastatin 80 mg, etc) for very high-risk patients. Then consider a stepped approach if needed.

Add ezetimibe first. It prevents one CV event for every 50 acute coronary syndrome patients treated for about 7 years...is well tolerated...and costs about $360/yr for the generic.

If LDL is still above 70 mg/dL, weigh pros and cons of injectable Praluent (alirocumab) or Repatha (evolocumab). Adding one of these PCSK9 inhibitors to a statin in patients with CV disease and other CV risks prevents about one CV event for every 70 patients treated for 2 to 3 yrs.

But Repatha costs about $4,150/yr...Praluent about $13,400/yr. Payer contracts may result in similar costs for either med.

Don't routinely add ezetimibe or a PCSK9 inhibitor for lower-risk patients with CV disease. Help them stick to their statin instead.

And don't start a bile acid sequestrant, fibrate, or niacin...these aren't shown to improve CV outcomes when added to a statin.

Further individualize treatment...for those ages 40 to 75 withOUT CV disease. Continue using the Am Coll of Cardiology/Am Heart Assn CV risk estimator as a starting point for shared decision making about statins.

Prescribe a high-intensity statin if 10-year CV risk is 20% or higher, since this level of risk is similar to having CV disease.

But if CV risk is 7.5% to 19.9%, look for "risk enhancers" BEFORE starting a statin. For example, consider family history, kidney disease, etc...or risk markers such as elevated coronary artery calcium (CAC) score.

In these PRIMARY prevention patients with additional CV risks, discuss starting a moderate-intensity statin (atorvastatin 20 mg, etc).

Continue using a statin in patients with diabetes ages 40 to 75.

Listen to PL Voices for insights from a guideline author. See our chart, 2018 ACC/AHA Cholesterol Guidelines, to get the full scoop.

Key References

  • J Am Coll Cardiol Published online Nov 8, 2018; doi:10.1016/j.jacc.2018.11.003
  • J Am Coll Cardiol Published online Nov 3, 2018; doi:10.1016/j.jacc.2018.11.004
  • J Am Coll Cardiol Published online Nov 3, 2018; doi:10.1016/j.jacc.2018.11.005
  • Medication pricing by Elsevier, accessed Dec 2018
Prescriber's Letter. Jan 2019, No. 350116



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