HealthDay News — New evidence-based guidelines for cholesterol management to prevent atherosclerotic cardiovascular disease no longer recommend specific LDL-cholesterol or non-HDL targets, and instead focus on tailoring statin therapy according to certain risk groups.

“This guideline represents a departure from previous guidelines because it doesn’t focus on specific target levels of LDL cholesterol. Instead it focuses on defining groups for whom LDL lowering is proven to be most beneficial,” Neil J. Stone, MD, chair of the expert panel that authored the guidelines, said in a statement.

The expert panel, composed of members of the American College of Cardiology (ACC) and American Heart Association (AHA), in conjunction with the National Heart, Lung and Blood Institute (NHLBI), performed the first update to cholesterol management guidelines in nine years.

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During a media conference, Stone and co-chair Donald M. Lloyd-Jones, MD, ScM, both of Northwestern University Feinberg School of Medicine in Chicago, emphasized the lack of evidence for treating to target, but added that regularly measuring LDL cholesterol levels will remain a mainstay of treatment.

“There have been no clinical trials in which they’ve taken an approach where they’ve titrated medication dosing to achieve a certain LDL level […] So we just couldn’t endorse that kind of approach,” Lloyd-Jones explained. “And yet, we’re not abandoning the measurement of LDL cholesterol, because it’s perhaps our best marker of understanding whether patients are going to achieve as much benefit as they can for the dose of statin they can tolerate. For the clinician, it’s also a very important marker of adherence.”

The main aim of the updated guidelines is to simplify treatment, so clinicians don’t have to worry about taking additional measures to lower LDL cholesterol if a patient has already been treated with an appropriate dose of statin therapy.

“In secondary prevention, what if your patient is on high-intensity statin therapy and gets an LDL-cholesterol level of 78 [mg/dL] and is adhering to an excellent lifestyle?” Stone said. “From our point of view, there is a large body of evidence that says he’s actually doing as good a job as he can possibly do. If he has to get to an optional goal of under 70 [mg/dL] as some would advocate, it means adding on medicines for which there is not proven benefit.”

Instead, the new recommendations assert that lifestyle modification before and in conjunction with cholesterol-lowering drug therapies is crucial.

The task force identified four major primary- and secondary-prevention patient groups it determined should be treated with satins based on results from randomized, controlled clinical trials that show treatment benefits outweigh the risks. These include:

  • Individuals with clinical atherosclerotic CVD
  • Individuals with LDL-cholesterol levels >190 mg/dL, such as those with familial hypercholesterolemia
  • Individuals aged 40 to 75 years with diabetes who have LDL cholesterol levels between 70 to 189 mg/dL, and without evidence of atherosclerotic CVD.
  • Those without clinical atherosclerotic CVD, who have LDL cholesterol levels of 70 to 189 mg/dL and an estimated 10-year risk of atherosclerotic CVD >7.5%.

For patients with atherosclerotic CVD or with LDL cholesterol levels >190 mg/dL, high-intensity statin therapy, such as with rosuvastatin (Crestor, AstraZeneca) 20 to 40 mg or atorvastatin 80 mg, should be prescribed to reduce LDL cholesterol levels at least 50%, the guidelines state.

For patients with contraindications or statin-associated adverse events, a moderate-intensity statin — defined as a drug that lowers LDL cholesterol 30% to 49% — should be used instead.

Clinicians should choose a moderate-intensity statin to treat patients aged 40 to 75 years with diabetes, but opt for a high-intensity statin if the patient also has a 10-year risk of atherosclerotic CVD exceeding 7.5%.

Treatment with either a moderate- or high-intensity statin is recommended for individuals aged 40 to 75 years without CVD or diabetes, but who has a 10-year risk of clinical events >7.5% and an LDL-cholesterol level from 70 to 189 mg/dL.

In addition to identifying and stratifying risk groups for statin therapy, the expert panel developed a new global risk assessment tool to predict the future risk for CVD and stroke. The model uses pooled cohort equations from the Framingham Heart Study, the Atherosclerosis Risk in Communities study, the Coronary Artery Risk Development in Young Adults, and the Cardiovascular Health Study.

However, some healthcare providers have expressed concern about how the new atherosclerotic risk score will perform, as it does not consider family history of future CVD, triglyceride levels, waist circumference, BMI, lifestyle habits or smoking history.

Additional recommendations in the guidelines focus on safety and providing guidance on the role of biomarkers and other noninvasive tests. More studies are needed to assess whether treating patients with high triglycerides or markers such as apolipoprotein B or LDL particles is useful, the panel added.


  1. Stone NJ et al. Circulation. 2013; doi:10.1161/​01.cir.0000437738.63853.7a.