Cholesterol control revised in the latest AHA/ACC guidelines

By Dr. Ananya Mandal, MDNov 11 2018

The American Heart Association and the American College of Cardiology have released their latest 121 page guidelines on risk assessment and management of high cholesterol for people who are at a greater risk of heart attacks or strokes.

The recommendations titled, “AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guidelines on the management of blood cholesterol: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines,” took 18 months for their guidelines to be prepared.

Cholesterol formation, fat, artery, vein, heart. Narrowing of a vein for fat formation. 3d rendering. Image Credit: Naeblys / Shutterstock

The last such guidelines were released in 2013 by the AHA/ACC and the group has said that the new recommendations focus on very low levels of LDL cholesterol as being beneficial. LDL cholesterol or “bad” cholesterol is known to contribute to plaque build up in the arteries and results in their narrowing. This raises the risk of heart attacks and strokes.

The latest recommendations were released last Saturday (10th November 2018) at their annual meeting in Chicago. The guidelines emphasizes on a healthy diet and regular exercise as the mainstay of keeping heart disease away. Heart disease, it states, is the leading killer in the US and all steps must be taken to prevent it.

The guidelines state that initial approach to raised cholesterol is changes in lifestyle following which, if uncontrolled, drugs are added. Statins are the staple cholesterol-lowering drugs and are safe and effective in reducing heart disease risk. These guidelines state that among people who have had a heart attack or a stroke, mere statins alone is not enough. Newer cholesterol lowering drugs need to be added to their daily regimen.

The recommendations suggest statins in cases of;

• No history of heart attacks or stroke and non-diabetic but LDL-C 70 mg/dL or higher and 7.5% or greater 10-year risk by the calculator
• No history of heart attacks or strokes but diabetic and LDL-C of 70 mg/dL or greater
• History of heart attacks or strokes but no heart failure
• LDL cholesterol ≥190 mg/dL or familial hypercholesterolemia.

According to the new guidelines those at a greater risk need to be administered statins in combination with ezetimibe. It works by lowering the absorption of cholesterol from the gut. For individuals who have very high levels of cholesterol or have a genetic risk of high cholesterol, two newer drugs are recommended. These are called proprotein convertase subtilisin/kexin type 9 or PCSK9 inhibitors. ;Two of the PCSK9 inhibitors available are Amgen Inc’s Evolocumab or Repatha and Regeneron Pharmaceuticals and Sanofi SA’s ; Alirocumab or Praluent. These were launched in 2015 and cost around $14,000 annually. The cost of these two agents has limited their use but they have been known to significantly lower cholesterol levels. To improve their uptake by the medical practitioners as well as by the health insurers, their prices have been slashed this year with Repatha at around $5,850 and Praluent at $4,500 - $6,600 annually.

The latest guidelines also include the earlier used calculator that can predict a person’s risk of heart disease over 10 years. Some of the risk factors re-emphasized include smoking, high blood pressure, family history of heart disease, ethnicity and race, premature menopause and presence of chronic kidney disease. Cholesterol testing is recommended from the age of 2 years among children with a family history of high cholesterol. Other children who do not have a family history of cholesterol need to be tested between ages 9 and 11 years. Coronary artery calcium (CAC) levels should be measured among individuals whose risk levels cannot be stratified say the authors.

The guidelines backed by 10 other medical societies and organizations is published in the Journal of the American College of Cardiology and in Circulation. The team was chaired by Scott M. Grundy, University of Texas Southwestern Medical Center at Dallas, and co-chaired by Neil J. Stone, Northwestern University, Chicago, Illinois.