Practice Guidelines

Cholesterol Management: ACC/AHA Updates Guideline


Am Fam Physician. 2019 May 1;99(9):589-591.

Author disclosure: No relevant financial affiliations.

Key Points for Practice

• A nonfasting plasma lipid profile can be obtained to estimate ASCVD risk and document baseline LDL-C in adults 20 years and older who are not on lipid-lowering therapy.

• Maximally tolerated statin therapy is recommended for patients 20 to 75 years of age with an LDL-C level of 190 mg per dL or greater.

• Moderate-intensity statin therapy should be initiated without calculating a 10-year ASCVD risk for patients 40 to 75 years of age with diabetes mellitus.

• Patients without diabetes at intermediate risk of ASCVD with LDL-C levels of 70 to 189 mg per dL should be treated with a moderate-intensity statin for a goal of 30% or greater reduction in LDL-C levels.

From the AFP Editors

The American College of Cardiology/American Heart Association (ACC/AHA) task force on clinical practice guidelines has updated its 2013 cholesterol guideline. The 2018 guideline narrows the use of the atherosclerotic cardiovascular disease (ASCVD) risk calculator, provides more guidance on the use of risk-enhancing factors in making statin therapy decisions, and recommends therapy options for achieving low-density lipoprotein cholesterol (LDL-C) targets. The updated guideline also includes recommendations for nonstatin lipid-lowering agents that can be used as statin add-ons to meet recommended LDL-C thresholds. A cornerstone of the guideline is to emphasize a heart-healthy lifestyle for all patients. A healthy lifestyle reduces ASCVD risk at all ages and can reduce the development of risk factors in younger patients.

Selected Strong Recommendations


Based on moderate-quality evidence from nonrandomized trials, measuring fasting or nonfasting plasma lipid levels is effective in estimating ASCVD risk and documenting baseline LDL-C in adults 20 years and older who are not on lipid-lowering therapy. When an initial nonfasting lipid profile reveals a triglyceride level of 400 mg per dL (4.5 mmol per L) or greater, a repeat lipid profile should be obtained to assess fasting triglyceride and baseline LDL-C levels in adults 20 years and older.


Based on high-quality evidence from randomized controlled trials (RCTs), high-intensity statin therapy should be instituted with a goal of lowering LDL-C levels by 50% or more in patients with ASCVD up to 75 years of age. If treatment is not tolerated, then moderate-intensity therapy should be used with a goal of achieving a 30% to 49% reduction in LDL-C levels. Based on nonrandomized trials, patients at very high risk (history of multiple ASCVD events or one event with multiple high-risk comorbidities) should

Author disclosure: No relevant financial affiliations.

Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.

This series is coordinated by Sumi Sexton, MD, Editor-in-Chief.

A collection of Practice Guidelines published in AFP is available at



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Apr 1, 2020

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