Clinical Practice Guideline

Cholesterol

Management of Blood Cholesterol

(Affirmation of Value, February 2019)

The guideline on Management of Blood Cholesterol was developed by the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and was categorized as Affirmation of Value by the American Academy of Family Physicians.

Key Recommendations

  • Individuals with LDL-C ≥ 190 mg/dL or triglycerides ≥ 500 mg/dL should be evaluated for secondary causes of hyperlipidemia.

  • A heart-healthy lifestyle should be emphasized for all individuals. Lifestyle therapy should be the primary intervention for metabolic syndrome.
  • Adults ≥ 21 years of age with a primary LDL-C ≥ 190 mg/dL should be treated with high-intensity statin therapy unless contraindicated.
  • Adults 40-75 years of age with an LDL-C 70-189 mg/dL without clinical ASCVD or diabetes and an estimated ten-year ASCVD risk ≥ 7.5% should be treated with moderate- to high-intensity statin therapy.

  • Adults 40-75 years of age with an LDL-C 70-189 mg/dL without clinical ASCVD or diabetes and an estimated ten-year ASCVD risk 5- 7.4% may consider moderate intensity statin therapy if there are additional risk factors. The decision to treat should include a discussion of the benefits and risks between the patient and clinician.
  • Adults 40-75 years of age with diabetes mellitus and an LDL-C 70-189 mg/dL should be treated with moderate-intensity statin therapy.
  • Individuals ≤ 75 years of age who have clinical ASCVD should be treated with high-intensity statin therapy unless contraindicated.
  • In adults with very high-risk ASCVD, addition of a nonstatin may be considered at a LDL-C threshold of 70 mg/dL (1.8 mmol/L). Very high-risk includes a history of multiple major ASCVD events or 1 major ASCVD event and multiple high-risk conditions.

The AAFP uses the category of “Affirmation of Value” to support clinical practice guidelines that provide valuable guidance, but do not meet our criteria for full endorsement. The primary reasons for not endorsing this guideline included:

  • An independent systematic review only addressed a small portion of the recommendations primarily focused on the addition of nonstatin therapy.
  • Many recommendations were based on low quality or insufficient evidence such as those addressing specific target levels for treatment and the use of coronary artery calcium scoring for decision-making.

These guidelines are provided only as assistance for physicians making clinical decisions regarding the care of their patients. As such, they cannot substitute the individual judgment brought to each clinical situation by the patient’s family physician. As with all clinical reference resources, they reflect the best understanding of the science of medicine at the time of publication, but they should be used with the clear understanding that continued research may result in new knowledge and recommendations. These guidelines are only one element in the complex process of improving the health of America. To be effective, the guidelines must be implemented.