The best management approach for elevated cholesterol involves both lifestyle modifications and pharmacological interventions, as recommended by the American College of Cardiology (ACC) and the American Heart Association (AHA).[1][3]
Lifestyle Modifications:
- Heart-healthy diet: Emphasize intake of vegetables, fruits, whole grains, lean proteins, and healthy fats while reducing saturated fats, trans fats, and cholesterol.
- Physical activity: Engage in at least 150 minutes of moderate-intensity or 75 minutes of high-intensity aerobic exercise per week.
- Weight management: Achieve and maintain a healthy weight.
- Smoking cessation: Avoid tobacco use.
- Moderation of alcohol intake: Limit alcohol consumption to no more than two drinks per day for men and one drink per day for women.
Statin Therapy:
- High-intensity statins (e.g., atorvastatin 40-80 mg, rosuvastatin 20-40 mg) are recommended for patients with clinical atherosclerotic cardiovascular disease (ASCVD) or those with LDL-C levels ≥190 mg/dL.
- Moderate-intensity statins (e.g., atorvastatin 10-20 mg, rosuvastatin 5-10 mg) are recommended for adults aged 40-75 years with diabetes mellitus and LDL-C levels ≥70 mg/dL, or those with a 10-year ASCVD risk of ≥7.5%.[1][3]
.
WHICH PATIENT GROUPS ARE AT HIGHER RISK FOR ELEVATED CHOLESTEROL?
Non-statin Therapies:
- Ezetimibe: Consider adding ezetimibe if LDL-C levels remain ≥70 mg/dL despite maximally tolerated statin therapy.
- PCSK9 inhibitors: Consider for patients at very high risk who do not achieve LDL-C goals with statins and ezetimibe.
- Bempedoic acid and inclisiran: Emerging options for patients who require additional LDL-C lowering.[3].
Risk Assessment:
- For adults aged 40-75 years without diabetes, a clinician-patient risk discussion should guide statin initiation, considering factors such as family history, LDL-C levels, and other risk enhancers.[1][3]
Regular monitoring of lipid levels and adherence to therapy is essential to ensure effective management and adjustment of treatment as needed.
Patients at higher risk for elevated cholesterol include several specific groups, as identified by the American College of Cardiology (ACC) and the American Heart Association (AHA) guidelines:
- Patients with severe hypercholesterolemia: Individuals with LDL-C levels ≥190 mg/dL (≥4.9 mmol/L) are at high risk and are candidates for immediate statin therapy without further risk assessment.[1-2]
- Adults with diabetes mellitus: Adults aged 40-75 years with diabetes are at higher risk and should start with a moderate-intensity statin. If they have multiple risk factors, a high-intensity statin may be indicated.[1-2]
- Adults aged 40-75 years: This age group, particularly those with LDL-C levels between 70-189 mg/dL (1.7-4.8 mmol/L), should have their 10-year ASCVD risk assessed. Those with a risk ≥7.5% are recommended for statin therapy.[1-2]
- Patients with risk-enhancing factors: These include family history of premature ASCVD, metabolic syndrome, chronic kidney disease, history of preeclampsia or premature menopause, chronic inflammatory disorders, high-risk ethnic groups (e.g., South Asian), and persistently elevated triglycerides.[1][4]
- Patients with hypertension: Poorly controlled hypertension is a significant risk factor for elevated cholesterol and ASCVD. These patients may benefit from statin therapy, especially if they have additional risk factors.[5]
Management strategies for these high-risk groups include lifestyle modifications such as a heart-healthy diet, physical activity, weight management, and smoking cessation, alongside pharmacological interventions like statins, ezetimibe, and PCSK9 inhibitors as appropriate.[1][6].
By Dr. Nanna
References
1. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline
on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American
Heart Association Task Force on Clinical Practice Guidelines.
Grundy SM, Stone NJ, Bailey AL, et al. Journal of the American College of Cardiology. 2019;73(24):e285-
e350. doi:10.1016/j.jacc.2018.11.003.
2. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline
on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American
Heart Association Task Force on Clinical Practice Guidelines.
Grundy SM, Stone NJ, Bailey AL, et al. Circulation. 2019;139(25):e1082-e1143.
doi:10.1161/CIR.0000000000000625.
3. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With
Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology
Joint Committee on Clinical Practice Guidelines.
Virani SS, Newby LK, Arnold SV, et al. Circulation. 2023;148(9):e9-e119.
doi:10.1161/CIR.0000000000001168.
4. Lipid Management for the Prevention of Atherosclerotic Cardiovascular Disease.
Michos ED, McEvoy JW, Blumenthal RS. The New England Journal of Medicine. 2019;381(16):1557-1567.
doi:10.1056/NEJMra1806939.
5. 2013 ACC/AHA Guideline Recommends Fixed-Dose Strategies Instead of Targeted Goals to
Lower Blood Cholesterol. Smith SC, Grundy SM. Journal of the American College of Cardiology.
2014;64(6):601-12. doi:10.1016/j.jacc.2014.06.1159.
6. Physical Activity as a Critical Component of First-Line Treatment for Elevated Blood Pressure
or Cholesterol: Who, What, and How?: A Scientific Statement From the American Heart
Association. Barone Gibbs B, Hivert MF, Jerome GJ, et al. Hypertension (Dallas, Tex. : 1979).
2021;78(2):e26-e37. doi:10.1161/HYP.000000000000019
Add comment
Comments