Cholesterol Guidelines Updated for the First Time Since 2013
On November 12, the American Heart Association (AHA) and the American College of Cardiology (ACC) updated the clinical guidelines for managing cholesterol for the first time since 2013. Unlike in the past, the new guidelines do not suggest a one-size-fits-all approach, but a more personalized one that allows patients to take a more active role in managing their health.
In addition to new assessments of patient risk for cardiovascular disease, the guidelines also give approval for new drugs to treat high-risk patients, and a treatment blueprint designed to help doctors and patients determine when it is appropriate to start taking cholesterol-lowering medication.
Dr. Michael Valentine, president of the ACC, said:
“High cholesterol is not one size fits all, and this guideline strongly establishes the importance of personalized care. Over the past 5 years, we’ve learned even more about new treatment options and which patients may benefit from them. By providing a treatment roadmap for clinicians, we are giving them the tools to help their patients understand and manage their risk and live longer, healthier lives.”
The go-to-treatment for high cholesterol that can’t be controlled by diet and exercise has traditionally been statin drugs. These medications can lower the risk of cardiovascular disease, but it isn’t always clear when a patient should start taking them. According to the new guidelines, patients should undergo calcium artery scans before being prescribed statins when it isn’t clear how high their risk is for cardiovascular disease.
When statins don’t work for a patient – such as when an individual has suffered a heart attack or stroke, or their LDL-C levels have not been lowered by statins – the guidelines recommend the use of 2 new, cholesterol-lowering drugs. The guidelines also recommend first adding a drug called ezetimibe, in addition to statins. For more severe cases, the guidelines recommend adding a PCSK9 inhibitor drug.
Additionally, the new guidelines call for doctors to consider screening children as young as 2 for cardiovascular risk factors if they have a family history of heart disease and high cholesterol. 
That might sound crazy, but consider this: U.S. Centers for Disease Control and Prevention (CDC) data from 2015-2016 shows that nearly 1 in 5 school age children and young people aged 6-19 years old in the U.S. is obese.
What’s more, the national obesity rate among children ages 2 to 19 in the U.S. is 18.5%, according to data from the National Health and Nutrition Examination Survey (NHANES).
The traditional view among doctors is that obesity and high cholesterol combined increases a person’s risk for cardiovascular disease, so the authors of the guidelines believe it is important to start looking out for kids’ heart health at a young age.
Dr. Sarah D. de Ferranti, chief of outpatient cardiology and director of preventive cardiology at Harvard Medical School’s Boston Children’s Hospital, said in a statement:
“It’s important that, even at a young age, people are following a heart-healthy lifestyle and understanding and maintaining healthy cholesterol levels.”
No More One-Size-Fits-All Targets
The new guidelines represent a shift in the way doctors and clinicians treat high cholesterol, but so, too, did the 2013 guidelines.
Amit Khera, MD, the director of the preventative cardiology program at the University of Texas Southwestern Medical Center, explained that, in the past, doctors encouraged patients to reach a low LDL target, like a “magic number.” For high-risk patients, that meant an LDL level of under 70 mg/DL in the blood.
The new guidelines have eliminated that target altogether. The goal now is to curb overall risk, rather than achieving a certain cholesterol number.
The 2018 revisions expand on those from 2013, “and give doctors and patients a little more to support their decision-making,” Khera said.
The updated guidelines also created new risk assessment tools that expand on the information collected from patients. The assessments still take into account standard risk factors like smoking and obesity, but also consider family history, ethnicity, and certain health conditions, such as premature menopause in women, when determining a patient’s risk for cardiovascular disease.
The hope is that in addition to helping clinicians compile a more comprehensive understanding of their patients’ risk status, there will be more factors for patients to consider, which will hopefully motivate them to take a more active role in reducing their risk.
“Guidelines are only as good as implemented, and if people aren’t going to use them, they’ll be for naught. But giving patients a little more control over their care is going to improve their adherence to care. They’ll be much more likely to keep taking the medications, which is what’s going to reduce the risk for cardiovascular disease.”
Reaching a “magic” cholesterol target number can seem daunting, whereas eating more vegetables, for example, might seem more doable for a lot of people.
A New Way of Thinking
A study published in January 2018 recommends statin drugs are given to an additional 9 million U.S. adults for preventing heart attack and stroke, sparking great debate among the medical community. 
It’s not difficult to see why many experts disagree with that assessment.
In recent years, studies have suggested that having high cholesterol does not increase a person’s risk for heart attack and stroke. Despite the availability of every type of low-fat and fat-free food imaginable, rates of both obesity and heart disease have continued to climb. If cholesterol was indeed the culprit in cardiovascular disease, you would expect to see those numbers declining.
Several renowned cardiologists have stated that cholesterol is vital for brain matter, nerves, and all other cellular structures in the body. Moreover, they say calcium deposits in the arteries are far more dangerous than cholesterol, as cholesterol is waxy and pliable, whereas calcium deposits are hard. Therefore, cardiologists say that doctors are focusing their attention in the wrong place.
Other noted cardiologists have gone on the record stating that saturated fat, believed to increase cholesterol levels, does not cause heart disease. They note that even in people with established heart disease, reducing saturated fat alone does not reduce heart attacks.
And while statins do work for many people, the drugs are linked to over 300 adverse events. Take a look at these headlines we have covered here at Natural Society.
- Statins Linked to 50% Increased Risk of Type 2 Diabetes (Type 2 diabetes is a risk factor for cardiovascular disease, so statins may actually increase some people’s risk.)
A Move in the Right Direction, Hopefully
Hopefully, the new guidelines will encourage people to become more engaged in lowering their risk of cardiovascular disease through diet and lifestyle, and reduce the need more even more Americans to start taking risky drugs that may or may not protect their heart health.
If you’ve been told you have dangerously-elevated cholesterol, you shouldn’t automatically assume you need to start taking pills. If your doctor suggests prescribing you a statin, discuss the idea of making lifestyle and dietary changes, such as eating a Mediterranean-style diet or including/avoiding other specific foods or food groups.
 Everyday Health
 USA Today
Julie Fidler is a freelance writer, legal blogger, and the author of Adventures in Holy Matrimony: For Better or the Absolute Worst. She lives in Pennsylvania with her husband and two ridiculously spoiled cats. She occasionally pontificates on her blog.