In 2018, the American College of Cardiology, the American Heart Association
(ACC/AHA) and ten additional professional organizations concerned with cardiovascular
health released 2018 Cholesterol Clinical Practice Guidelines. The
new guidelines for managing cholesterol are more complicated. They keep some
features of the 2013 risk assessment framework, including a stress on lifestyle measures
relating to diet, weight, blood pressure, and physical activity. The new guidelines
continue reliance on the calculation of 10-year CVD risk for therapy recommendations,
but for some patients with high CVD risk, they recommend a LDL-C
target of 70 mg/dl or lower. They further personalize risk assessment and decisions
about treatment, and they also emphasize that the lower a person’s LDL-C the better
for CVD health and include the option of adding non-statin drugs for people at high

The following summary of the guidelines describes interventions based on the
health status of individual patients—but don’t rely on this summary for decisions
relating to CVD prevention or therapy, your health care provider should be consulted.

The 2018 guidelines are available at,
The guidelines consider three groups to be at high CVD risk and therefore are
candidates for statins and possibly additional cholesterol-lowering drugs:

• People with a history of CVD, such as a heart attack, angina, or stroke
• People ages 40 to 75 who have diabetes (which greatly increases CVD risk)
• People with very high LDL-C (above 190 mg/dl), often from familial

For others, between the ages of 40 and 75, the guidelines recommend using a risk
calculator, such as the ASCVD Risk Estimator Plus, (online at
ASCVD-Risk-Estimator-Plus/#!/calculate/estimate/), or the 2013 American Heart
Association/American College of Cardiology (AHA/ACC) risk calculator (online at to estimate 10-year risk of a major CVD event. The following
treatment recommendations differ for various categories of risk.

Low risk
A person with a 10-year risk below 5% is considered to be at low risk and usually
not a candidate for a statin. However, as already noted, avoiding many years of
risk factors such as high cholesterol and high blood pressure suggests starting statin
treatment for someone who is at low risk mainly because of their young age.

High risk (10-year risk above 20%)
Take a high-dose statin to reduce LDL by at least 50%.

Intermediate risk (10-year risk 7.5% to 20%) and borderline risk (10-year risk 5% to 7.5%)
Consider well known major risk factors such as smoking, hypertension, obesity, and
inactivity; in addition, evaluate of other “risk-enhancing factors,” including:
• Family history of premature CVD; for males, that means a heart attack or
stroke before age 55; for females, before age 65
• Persistently elevated LDL-C (160 to 190 mg/dl)
• Persistently elevated triglycerides (175 mg/dl or above)
• Metabolic syndrome, characterized by three or more of the following:
abdominal obesity, high blood pressure, high blood sugar, high triglycerides,
and low HDL-C
• Chronic kidney disease
• High-risk ethnicity (such as South Asian)
• Chronic inflammatory disorders (such as rheumatoid arthritis or psoriasis) or
• History of early menopause (before age 40) or pregnancy-related conditions
that increase CVD risk, such as preeclampsia

Start treatment on the basis of this evaluation and after a discussion about the pros
and cons of statins with a health care provider. Make a shared decision. If treatment
is decided on, the goal is to reduce LDL cholesterol by at least 30% with a
moderate-intensity statin. A coronary artery calcium (CAC) scan may help make
the decision about treatment.

The treatment guidelines focus primarily on people ages 40 to 75 because almost
all of the major clinical trials have involved that age group. They do advise people
under 40 or over 75 with CVD, diabetes, or very high LDL-C to take statins. For
others in these age groups, the benefits and risks of statin therapy should be considered
on an individual basis. The guidelines call for assessing adherence and percentage response to LDL-C lowering
medications and lifestyle changes with repeat lipid measurement four to 12
weeks after statin initiation or dose adjustment, repeated at three to 12 months as

This blog presents opinions and ideas and is intended to provide helpful general information. I am not engaged in rendering advice or services to the individual reader. The ideas, procedures and suggestions in that are presented are not in any way a substitute for the advice and care of the reader’s own physician or other medical professional based on the reader’s own individual conditions, symptoms or concerns. If the reader needs personal medical, health, dietary, exercise or other assistance or advice the reader should consult a physician and/or other qualified health professionals. The author specifically disclaims all responsibility for any injury, damage or loss that the reader may incur as a direct or indirect consequence of following any directions or suggestions given in this blog or participating in any programs described in this blog or in the book, The Building Blocks of Health––How to Optimize Your Health with a Lifestyle Checklist (available in print or downloaded at Amazon, Apple, Barnes and Noble and elsewhere). Copyright 2021 by J. Joseph Speidel