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Cholesterol Guidelines
In 2013, the American College of Cardiology and the American Heart Association released the first major US
guidelines on the management of cholesterol since the Adult Treatment Panel III (ATP-III) Guidelines were
published in 2001.
At the time that the 2013 AHA/ACC Cholesterol Guidelines were published, a separate guideline panel from the
AHA/ACC published a guideline about lifestyle changes (diet and exercise) that could be made to reduce
ASCVD risk.

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Highlights of ACC/AHA Recommendations (2013)
Increased evidence-based rigor.
Atherosclerotic cardiovascular disease (both stroke and myocardial infarction) targeted for prevention.
Low density lipoprotein cholesterol (LDL-c) goals no longer recommended as treatment targets.
Only one pharmacologic agent recommended for lowering cholesterol: HMG Co-A Reductase Inhibitors
(statins).
Four Indications for Statin Therapy
Indication for Statin
1.
Individuals with clinical ASCVD
Acute coronary syndrome (MI or unstable angina)
Stroke or TIA felt to be atherosclerotic in origin
Peripheral vascular disease
High-intensity statin therapy
2.
Individuals 40-75 years with diabetes
Consider statins if <40 or >75 years, depending on risks/benefits
and patient preferences
Moderate-intensity statin
High-intensity statin if ASCVD
risk >7.5%
3.
Individuals > 21 years with LDL-c > 190 mg/dL
These patients often have a genetic hyperlipidemia and have high
ASCVD risk
High-intensity
4.
Individuals 40-75 years with 10 year ASCVD risk >7.5%
Calculated using the Pooled Cohort ASCVD Risk Equations.
Moderate- or high-intensity

Low Intensity Statins Moderate Intensity Statins High Intensity Statins
Simvastatin 10 mg
Pravastatin 10-20 mg
Lovastatin 20 mg
Fluvastatin 20-40 mg
Pitavastatin 1 mg
Atorvastatin 10-20 mg
Rosuvastatin 5-10 mg
Simvastatin 20-40 mg
Pravastatin 40-80 mg
Lovastatin 40 mg
Fluvastatin 40 mg bid
Pitavastatin 2-4 mg
Atorvastatin 40-80 mg
Rosuvastatin 20-40 mg
Counting risk factors no longer recommended for creating cholesterol management plan.
Atherosclerotic Cardiovascular Disease Risk Factors
The 2013 Cholesterol Guidelines recommend that physicians assess ASCVD risk using the Pooled Cohort Risk
Equations, a risk tool that assesses a patient's 10-year risk of ASCVD on the basis of the major risk factors.
It is reasonable to assess traditional ASCVD risk factors, including fasting lipids, every 4 to 6 years in adults 20
to 79 years of age who are free from ASCVD and to estimate 10-year ASCVD risk every 4 to 6 years in adults
40-79 years of age without ASCVD.
In the event that a further delineation of a patient's risk is needed, the guidelines recommended several options
for testing that have been shown to contribute to the assessment of risk beyond what can be obtained with the
major risk factors.
The following table provides more detail about these risk factors.
Major Risk
Factors
Explanation
Age
Atherosclerosis is a progressive illness and a patient's risk for ASCVD events increases with
each decade.
The age-related rise in the incidence of ASCVD begins approximately ten years earlier in men
than in women (>45 for men, >55 for women). In this sense, being male is a risk factor for
Gender ASCVD. It must be remembered, however, that ASCVD is the leading cause of death in
women as well.
Hypertension Hypertension is a risk factor irrespective of whether it is well-controlled with treatment.
Systolic blood
pressure
Independent of the diagnosis of hypertension, the most recent systolic blood pressure is a risk
factor. It is used in risk prediction models such as the Pooled Cohort Equations calculator and
the Framingham Risk Score.
Total and HDL
cholesterol
Elevated total cholesterol and low HDL-c are both associated with incident ASCVD. HDL-c
has no clear threshold below which risk occurs, but low HDL-c is frequently defined as being
below 40 mg/dL. Additionally, the ratio of these two values adds to prediction of risk, with
higher ratios indicating higher risk.
Diabetes
mellitus
Individuals with diabetes have markedly increased risk of ASCVD, approaching that of
individuals with known prior ASCVD.
Smoking status
Smoking status (generally considered as current smoking status) represents the single greatest
environmental risk factor for ASCVD.
Additional
Risk Factors
That May Be
Considered
These risk factors may be obtained when there is still clinical uncertainty after
assessing risk using the Pooled Cohort Equations
Family History
Increased risk of ASCVD is associated with a first degree family history of premature CVD.
This is defined as:
Male first degree relative < 55 years
Female first degree relative < 65 years
Family history has the distinct advantage of being free to obtain.
Highly sensitive
c-reactive
protein (hs-
CRP)
Elevated hs-CRP, defined as > 2 mg/L, is associated with ASCVD risk. Furthermore, the
JUPITER trial demonstrated that treating patients having normal LDL-c but elevated hs-CRP
with statins reduces incident CVD.
Coronary
artery calcium
(CAC)
Measured by CT scanning, CAC scores have demonstrated great utility in refining CVD risk
beyond the major risk factors. Elevated CAC is defined as a score > 300 Agatston units. The
benefit of CAC scoring is limited by the radiation exposure and high cost of CT scanning.
Ankle-brachial
index (ABI)
The ABI (the ratio of ankle to brachial systolic blood pressures) is decreased when
peripheral vascular disease is present. The ABI is considered abnormal when it is below 0.9. It
is safe and inexpensive to obtain.
Pooled Cohort Equations developed to estimate ASCVD risk.
Studies demonstrate that cholesterol management is likely to be most effective when based on a patient's
calculated risk of incident ASCVD.The prior ATP-III guidelines relied upon the Framingham Risk Score (FRS),
which was based upon follow-up data from the predominantly White population of Framingham, MA in the
1950s.
The 2013 AHA/ACC Risk Assessment Guidelines developed a novel risk calculator derived from data from
several large cohort studies in the 1990s. Termed the Pooled Cohort Equations, this new calculator has the
advantages of being based on more recent data and on data that is more racially diverse. Furthermore, the new
calculator estimates a patient's risk of ASCVD (stroke and MI) rather than just CAD (as in the FRS)
The Pooled Cohort Equations produces a patient's 10-year risk of incident ASCVD based upon their major risk
factors (age, gender, smoking status, hypertension and systolic blood pressure, diabetes, total and HDL
cholesterol).
The risk calculator may be downloaded from the American Heart Association website. Smartphone apps are
also freely available.
Controversy surrounding the Pooled Cohort Equations. Concern has been raised that the Pooled Cohort
Equations may overestimate risk in many patients, subjecting low-risk patients to long-term statin therapy. If
uncertainty exists after obtaining a patient's 10-year ASCVD risk, it would be reasonable to further refine his/her
risk using one of the additional risk factors suggested by the 2013 Risk Assessment Guidelines.
Comparison of ATP-III (2001) vs. ACC/AHA (2013) Guidelines for Cholesterol Management
Difference ATP-III (2001) ACC/AHA Cholesterol Guidelines (2013)
Evidence
Base
Relied heavily on observational data in
making recommendations. Evidence
quality not reported with
recommendations.
Restricted, when able, to randomized trial data and
meta-analyses in making recommendations. All
recommendations accompanied by rating of evidence
quality.
Target
Diseases for
Prevention
Acute coronary syndrome, fatal MI.
Acute coronary syndrome, fatal MI, stroke, fatal
stroke - together termed atherosclerotic
cardiovascular disease (ASCVD).
Treatment
Targets
Therapy guided by LDL-c and non-
HDL-c goals, which were determined by
a patient's risk factors and 10-year risk
of MI.
No LDL-c treatment targets included. Instead,
recommended four categories of patients who are
candidates for statin therapy.
Pharmacologic
Options
Statins, fibric acid derivatives, niacin, bile
acid sequestrants. Any agent that could
lower LDL-c or non-HDL-c.
Statins are the only recommended class, as they are
the only agents with trial data showing improved
ASCVD outcomes.
Risk
Assessment
Tool
Framingham Risk Score
Pooled Cohort Equations
Lifestyle recommendations
Fortunately, the AHA/ACC lifestyle recommendations are similar for almost all adults, and are based on
moderate (exercise) and high (diet) quality evidence.
Diet
High-quality evidence from two clinical trials indicate the benefit of a Mediterranean diet in the prevention of
CVD. Further trials demonstrate the benefit of a low-salt diet in lowering blood pressure. The following table
summarizes the diet recommendations for both LDL-c lowering and BP lowering:
Category Recommendation
Evidence
Quality
All adults
- Mediterranean-style diet (the DASH dietary pattern achieves this)
Rich in:
Vegetables
Fresh fruits
Whole grains
Lean meats: poultry, pork, fish
Legumes: e.g. lentils
Non-tropical vegetable oils: e.g. olive oil
Tree nuts: pecans, cashews, etc. (not peanuts)
Low in:
Sugar-sweetened beverages
Sweets
Red meats
A (strong)
Those needing LDL
lowering
(recommendations should
be
made irrespective of
whether
the patient has an
indication for a statin)
- Reduce percent of calories from saturated fat, aiming for a goal of 5%
to 6% of calories from saturated fats.
Saturated fats come from:
Animal fats (meat and dairy)
Some vegetable oils (particularly coconut and palm oils)
- Reduce percent of calories from trans fat. These come from:
Partially hydrogenated oils
Oils used for deep frying
Vegetable shortenings
Many pre-packaged baked goods and chips
A (strong)
A (strong)
Those needing BP
lowering
(unlike with cholesterol
managment,
if a patient can lower his
BP with diet,
he may avoid the need for
medications)
- Reduce sodium intake

- Limit sodium intake to 2,400 mg per day
- Limiting of sodium to 1,500 mg/day further lowers BP
A (strong)


B
(moderate)

Exercise
On the basis of moderate quality evidence, all adults are encouraged to engage in moderate-to-vigorous intensity
physical activity 3-4 times per week for 40 minutes per session.
Author
David Anthony, MD, MSc; Alpert Medical School of Brown University
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