Month: June 2019

2018 Cholesterol Clinical Practice Guidelines: Synopsis of the 2018 American Heart Association/American College of Cardiology/Multi society Cholesterol Guideline

2018 Cholesterol Clinical Practice Guidelines: Synopsis of the 2018 American Heart Association/American College of Cardiology/Multi society Cholesterol Guideline

CLINICAL GUIDELINES |4 JUNE 2019 Annals Of Internal Medicine

According to the Centers for Disease Control and Prevention, heart disease is the leading cause of death in the United States, including for African American, Hispanic, and white persons (1) and for both women and men. The leading cause of death attributable to cardiovascular disease (CVD) in the United States is coronary heart disease (43.8%), followed by stroke (16.8%)—the 2 components of fatal atherosclerotic CVD (ASCVD) (2). The economic impact of ASCVD is large: It accounted for 14% of total health expenditures in 2013 to 2014, more than any major diagnostic group.

The American Heart Association and American College of Cardiology (AHA/ACC), with the support of 10 collaborating organizations, have recently released their 2018 cholesterol guideline (3). In addition, they have released a companion special report on the use of risk assessment tools to guide decision making in primary prevention 


The guideline endorses a heart-healthy lifestyle beginning in childhood to reduce lifetime risk for ASCVD. It contains several new features compared with the 2013 guideline. For secondary prevention, patients at very high risk may be candidates for adding nonstatin medications (ezetimibe or proprotein convertase subtilisin/kexin type 9 [PCSK9] inhibitors) to statin therapy. In primary prevention, a clinician–patient risk discussion is still strongly recommended before a decision is made about statin treatment. The AHA/ACC risk calculator first triages patients into 4 risk categories. Those at intermediate risk deserve a focused clinician–patient discussion before initiation of statin therapy. Among intermediate-risk patients, identification of risk-enhancing factors and coronary artery calcium testing can assist in the decision to use a statin. Compared with the 2013 guideline, the new guideline gives more attention to percentage reduction in low-density lipoprotein cholesterol as a treatment goal and to long-term monitoring of therapeutic efficacy. To simplify monitoring, nonfasting lipid measurements are allowed.

Synopsis of Recommendations

1. Healthy lifestyle over the lifespan. A healthy lifestyle reduces ASCVD risk at all ages. In younger persons, healthy lifestyle can reduce development of risk factors, can prevent the need for subsequent statin use, and is foundational therapy for ASCVD risk reduction. In young adults aged 20 to 39 years, an assessment of lifetime risk facilitates the clinician–patient risk discussion and emphasizes intensive lifestyle efforts. In all age groups, lifestyle therapy is the primary intervention for metabolic syndrome.

2. Use of maximally tolerated doses of statins in secondary prevention of ASCVD. In patients with clinical ASCVD, the guideline recommends reduction of low-density lipoprotein cholesterol (LDL-C) levels with high-intensity or maximally tolerated statin therapy. The more LDL-C is reduced during statin therapy, the greater the subsequent risk reduction will be. High-intensity statins typically reduce LDL-C levels by an average of at least 50%, which is an attainable goal in most patients with ASCVD.

3. Use of nonstatin medications in addition to statin therapy for patients at very high risk for ASCVD. Very high risk is defined as a history of multiple major ASCVD events, or 1 major ASCVD event and multiple other high-risk conditions. In very-high-risk ASCVD, the guideline recommends an LDL-C threshold of 1.8 mmol/L (70 mg/dL) as reasonable for adding a nonstatin medication (ezetimibe or proprotein convertase subtilisin/kexin type 9 [PCSK9] inhibitors) to maximally tolerated statin therapy. In patients who had very high risk, had a baseline LDL-C level of approximately 1.8 mmol/L (70 mg/dL), and were receiving statin therapy, addition of ezetimibe reduced risk for major events by 2 percentage points (6). Two RCTs recruited patients at very high risk who were receiving maximally tolerated doses of statins, had LDL-C levels greater than 1.8 mmol/L (70 mg/dL) (average, about 2.3 mmol/L [90 mg/dL]), and were treated with PCSK9 inhibitors for approximately 3 years (7, 8). Addition of PCSK9 inhibitors reduced risk for subsequent ASCVD events by about 15%. On the basis of these RCTs, the guideline states that addition of ezetimibe to maximally tolerated statin therapy is reasonable when LDL-C levels are 1.8 mmol/L (70 mg/dL) or higher. In patients at very high risk whose LDL-C levels remain above this threshold while they receive maximally tolerated statin and ezetimibe therapy, the guideline suggests that a PCSK9 inhibitor is a reasonable addition, although long-term safety (>3 years) is uncertain and cost-effectiveness was low at mid-2018 list prices. Some prescription programs have recently been initiated to reduce the cost of PCSK9 inhibitors. As cost decreases, cost-effectiveness will increase (9).

4. Severe primary hypercholesterolemia, often starting in childhood. In patients with primary, severe hypercholesterolemia (LDL-C level ≥4.9 mmol/L [≥190 mg/dL]), calculating 10-year ASCVD risk is not necessary. Maximally tolerated statin therapy is required to reduce LDL-C levels toward a lower risk range. If the LDL-C level remains at or above 2.6 mmol/L (100 mg/dL), adding ezetimibe is reasonable. If the patient still has an LDL-C level above this threshold while receiving a statin plus ezetimibe and has multiple factors that increase subsequent risk for ASCVD events, a PCSK9 inhibitor may be considered, although long-term safety (>3 years) is uncertain and economic value is low based on list prices from mid-2018.

5. Adults aged 40 to 75 years with diabetes mellitus and an LDL-C level of 1.8 mmol/L (70 mg/dL) or higher. In these patients, the guidelines recommend starting moderate-intensity statin therapy without the need to calculate 10-year ASCVD risk. In patients with diabetes and higher risk, especially those who have multiple risk factors or are aged 50 to 75 years, use of a high-intensity statin is reasonable to reduce the LDL-C level by at least 50%.

6. Clinician–patient risk discussion. In adults aged 40 to 75 years who are evaluated for primary ASCVD prevention, the guidelines continue to recommend a clinician–patient risk discussion before statin therapy is started. Risk discussion should include review of major risk factors (such as cigarette smoking and elevated levels of blood pressure, LDL-C, hemoglobin A1c level [if indicated], or calculated 10-year risk for ASCVD), risk-enhancing factors (see recommendation 8), the potential benefits of lifestyle and statin therapies, the potential for adverse effects and drug–drug interactions, consideration of costs of statin therapy, and patient preferences and values in shared decision making.

7. Adults aged 40 to 75 years without diabetes mellitus who have LDL-C levels of at least 1.8 mmol/L (70 mg/dL), and a 10-year ASCVD risk of 7.5% or higher. In this population, the guidelines recommend moderate-intensity statin therapy if a discussion of treatment options favors statins. Patients without ASCVD are categorized and stratified for risk by age, coexisting conditions, and risk factors (Figure). When those with diabetes or LDL-C levels above 4.9 mmol/L (190 mg/dL) are excluded, RCT evidence for the benefit of statin therapy in persons aged 40 to 75 years continues to accumulate (10). Patients in this age range are triaged into 4 categories of 10-year risk for ASCVD: low (<5%), borderline (5% to 7.4%), intermediate (7.5% to 19.9%), and high (≥20%). In the latter category, the guideline recommends high-intensity statin therapy because of its proven benefit. Evidence from RCTs supports the efficacy of statin therapy for patients whose 10-year risk is 5% or higher. Nonetheless, in those with borderline or intermediate risk, clinical judgment is required to initiate statin treatment on the basis of risk–benefit considerations and patient preferences.

8. Decision making in primary prevention in adults aged 40 to 75 years. The guideline endorses a 3-tiered decision process for treatment in adults aged 40 to 75 years with borderline (5% to 7.4%) or intermediate (7.5% to 19.9%) risk for ASCVD. The decision process begins with estimation of 10-year risk. As in prior guidelines, 10-year risk of 7.5% or higher does not result in automatic statin assignment. To personalize risk, the current guideline recommends evaluation of risk-enhancing factors—that is, stable factors that associate with ASCVD beyond the major risk factors incorporated into the risk calculator. These include family history of premature ASCVD; LDL-C levels of 4.1 mmol/L (160 mg/dL) or higher; metabolic syndrome; chronic kidney disease; history of preeclampsia or premature menopause (in women); chronic inflammatory disorders; high-risk ethnicity, such as South Asian ancestry; triglyceride levels persistently elevated above 2.0 mmol/L (175 mg/dL); and, if measured, elevations in apolipoprotein B (may be especially useful if hypertriglyceridemia >2.3 mmol/L [>200 mg/dL] persists), high-sensitivity C-reactive protein levels of 19.0476 nmol/L (2.0 mg/L) or higher, lipoprotein(a) levels with elevations above 125 nmol/L (50 mg/dL) (especially useful in those with a family history of premature ASCVD), or reduced ankle–brachial index. Presence of risk-enhancing factors in patients at intermediate risk favors statin therapy. In addition, if risk status remains uncertain, measurement of coronary artery calcium (CAC) can be considered.

9. CAC scoring to improve risk stratification. In adults who do not have diabetes, are aged 40 to 75 years, have LDL-C levels of 1.8 to 4.9 mmol/L (70 to 189 mg/dL), and have a 10-year risk of 7.5% to 19.9% as estimated by the pooled cohort equations (PCEs), but who are uncertain about statin benefit, CAC scoring may help resolve the uncertainty. If the CAC score is 0 Agatston units, statin therapy may be withheld or delayed, except in cigarette smokers and those with a strong family history of premature ASCVD or diabetes. A CAC score of 1 to 99 units favors statin therapy, especially in patients older than 55 years. For any patient, if the CAC score is at least 100 Agatston units or is at or above the 75th percentile, statin therapy is indicated unless otherwise deferred by the outcome of a clinician–patient risk discussion.

10. Follow-up for adherence and adequacy of response. The current guideline continues to recommend assessment of adherence to medications and lifestyle and percentage change in LDL-C level at 4 to 12 weeks after statin initiation or dosage adjustment; this assessment should be repeated every 3 to 12 months as needed. Clinicians may often underestimate adherence unless specific questions are asked (11).

Patient Education: Diet and Health

Patient Education: Diet and Health

The food choices we make can have an important impact on our health. However, expert opinions continue to change about which and how much of these foods are optimal.

FRUITS AND VEGETABLES — Several studies have demonstrated important health benefits of eating fruits and vegetables.

  • Increased intake of fruits and vegetables is linked to a lower risk of premature death.
  • Fruits and vegetables decrease the risk of cardiovascular diseases including coronary heart disease (CHD), stroke, and death from CHD.
  • High intake of fruits and vegetables may reduce the risk of developing cancer. Tomato and tomato-based foods may be beneficial at lowering the risk of prostate cancer.
  • Recommended intake is at least five servings of fruits and/or vegetables every day.

FIBER — Eating a diet that is high in fiber can decrease the risk of coronary heart disease (CHD), colon cancer, and death. Eating fiber also protects against type 2 diabetes and eating soluble fiber (such as that found in vegetables, fruits, and especially legumes) may help control blood sugar in people who already have diabetes.

The recommended amount of dietary fiber is 25 grams per day for women and 38 grams per day for men. Many breakfast cereals, fruits, and vegetables are excellent sources of dietary fiber. By reading the product information panel on the side of the package, it is possible to determine the number of grams of fiber per serving.

GRAINS AND SUGAR — Whole grain foods (like 100 percent whole wheat bread, steel cut oats, and wild/brown rice) should be chosen over foods made with refined grains (like white bread and white rice). Regularly eating whole grains has been shown to help weight loss and lower the risk of diabetes. Regularly consuming refined grains and added sugars has been associated with weight gain and increased risk of diabetes.

FAT — Eating foods higher in healthy fats and lower in unhealthy fats may reduce the risk of coronary heart disease (CHD).

The type of fat consumed appears to be more important than the amount of total fat. Trans fats should be avoided in favor of polyunsaturated fats, particularly those polyunsaturated fats found in fish (omega 3). Other sources of polyunsaturated fats that may be beneficial include certain oils, nuts, and seeds (like corn oil, flax seeds, and walnuts).

Trans fats appear on food labels as “partially hydrogenated oils” and are solid at room temperature. They are found in many margarines and commercial baked goods as well as in oils kept at high temperatures for a long period, such as frying vats in fast food restaurants.

Although saturated fats (found in animal products such as cheese, butter, and red meat) have typically been viewed as unhealthy, and monounsaturated fats (found in combination with other fats in many oils, such as olive oil) as healthy, newer evidence suggests that saturated and monounsaturated fats do not significantly increase or decrease the risk of CHD, although saturated fats raise cholesterol levels.

If cutting back on certain fats, it is important not to replace them with refined carbohydrates (eg, white bread, white rice, most sweets). Increases in refined carbohydrate intake may lower levels of high-density lipoprotein (HDL) cholesterol (good cholesterol), which actually increases the risk of CHD.

RED MEAT — It is now well-established that regularly eating red meat, particularly processed meats (like salami, pepperoni, and ham), is detrimental to health. It increases the risk of numerous diseases such as cancer, cardiovascular disease, and diabetes.

FOLATE — Folate is a type of B vitamin that is important in the production of red blood cells. Low levels of folate in pregnant women have been linked to a group of birth defects called neural tube defects, which includes spina bifida and anencephaly. Vitamins containing folate and breakfast cereal fortified with folate are recommended as the best ways to ensure adequate folate intake.

ANTIOXIDANTS — The antioxidant vitamins include vitamins A, C, E, and beta-carotene. Many foods, especially fruits and vegetables, contain these vitamins as well as have additional antioxidant properties. Studies have not clearly shown that antioxidant vitamins help prevent disease, specifically cancer, and some studies show they may cause harm. There is no evidence to support taking antioxidant vitamin supplements, except for individuals who have specific vitamin deficiencies.

CALCIUM AND VITAMIN D — Adequate calcium and vitamin D intake are important, particularly in women, to reduce the risk of osteoporosis. A health care provider can help to decide if supplements are needed, depending upon a person’s dietary intake of calcium and vitamin D. Although the optimal level has not been clearly established, experts recommend that premenopausal women and men consume at least 1000 mg of calcium per day and postmenopausal women should consume 1200 mg per day. No more than 2000 mg of calcium should be consumed per day.

For vitamin D, 800 international units (20 micrograms) per day is recommended for adults over 70 years old and postmenopausal women. For other adults, the optimal intake is not clearly established, but 600 international units (15 micrograms) per day is generally recommended.

ALCOHOL — Moderate alcohol intake may reduce the risk of heart disease. However, drinking is also associated with many adverse events. Regularly drinking alcohol increases the risk of breast cancer in women; cancers of the mouth, esophagus, throat, larynx, and liver; other illnesses such as cirrhosis and alcoholism; and injuries and other trauma-related problems, particularly in men.

Based on the trade-off between these risks and benefits, the United States Dietary Guidelines recommend alcohol intake in moderation, if at all. This means no more than one drink per day for women and up to two drinks per day for men. Those who do not drink alcohol do not need to start.

Drinking is discouraged for those under 40 years who are at low risk of cardiovascular disease because the risks are likely to outweigh the benefits in this group.

CALORIC INTAKE — Of all aspects of diet, calories are possibly the most important when it comes to good health and preventing disease. Too many calories lead to weight gain and obesity. Excess weight is linked to premature death as well as an increased risk of cardiovascular disease, diabetes, hypertension, numerous cancers, and other important diseases.

The total number of calories a person needs depends upon the following factors:

  • weight
  • age
  • gender
  • height
  • activity level

GENERAL RECOMMENDATIONS FOR A HEALTHY DIET — Eat lots of vegetables, fruits, and whole grains and a limited amount of red meat. Get at least five servings of fruits and vegetables every day. Tips for achieving this goal include:

  • Make fruits and vegetables part of every meal. Eat a variety of fruits and vegetables. Frozen or canned can be used when fresh isn’t convenient.
  • Eat vegetables as snacks.
  • Have a bowl of fruit all the for kids to take snacks from.
  • Put fruit on your cereal.
  • Consume at least half of all grains as whole grains (100 percent whole wheat bread, brown rice, whole grain cereal), replacing refined grains (like white bread, white rice, refined or sweetened cereals)
  • Choose smaller portions and eat more slowly.

Cut down on unhealthy fats (trans fats and saturated fats) and consume more healthy fats (polyunsaturated and monounsaturated fat). Tips for achieving this goal include:

  • Choose chicken, fish, and beans instead of red meat and cheese.
  • Cook with oils that contain polyunsaturated and monounsaturated fats, like corn, olive and peanut oil.
  • Choose margarines that do not have partially hydrogenated oils. Soft margarines (especially squeeze margarines) have less trans fatty acids than stick margarines.
  • Eat fewer baked goods that are store-made and contain partially hydrogenated fats (like many types of crackers, cookies, and cupcakes).
  • When eating at fast food restaurants, choose healthy items for yourself as well as your family, like broiled chicken or salad.
  • If choosing prepared or processed foods, choose those labeled “zero trans-fat.” They may still have some trans-fat, but likely less than similar choices not labeled “zero.”

Avoid sugary drinks and excessive alcohol intake. Tips for achieving this goal include:

  • Choose non-sweetened and non-alcoholic beverages, like water, at meals and parties.
  • Avoid occasions centered around alcohol.
  • Avoid making sugary drinks and alcohol an essential part of family gatherings.

Keep calorie intake balanced with needs and activity level.

Gutchek Introduction

Gutchek Introduction

Twenty-three years ago, I started writing articles to give updates to my fellow colleagues under the banner “JUST SO YOU KNOW.” As president of Unity Hospital medical and dental staff, these articles were hugely popular and have become my tradition ever since. In late 80s and early 90s, I was writing articles regarding common GI medical issues to educate our physicians under the name GUTCHEK as newsletter. Once I had set up our practice website in late 90s, articles were then posted under and were enjoyed by patients and physicians alike.

Now as a retired Gastroenterologist, I am beginning a new chapter as a blogger. Going forward, will contain common digestive disease-related pearls for the benefit of patients. Also, this website will periodically post articles of medical and non-medical interest from other sources as well. I will offer surveys time to time. will offer free information to the general public about their digestive disorder symptoms. Within Monroe County, I will be able to provide support about seeking experts in the area.

I am open to suggestions as to what other content to include on

Tarun Kothari, MD, FACG, FACP

Disclaimer Notice: and the information contained within is provided for general education and informative purposes only. Articles do not constitute medical advice. Please consult with your own health care provider for proper diagnosis and treatment.