How is high cholesterol treated if I am white?

The 2018 American Heart Association (AHA)/American College of Cardiology (ACC) Guideline on the Management of Blood Cholesterol recommends healthy lifestyle practices and statins for all adults with high cholesterol, defined as low density lipoprotein cholesterol (LDL-C) ≥190 mg/dL.¹ The guideline also recommends statins for some people with LDL-C <190 mg/dL after an assessment of their risk for future atherosclerotic cardiovascular disease (ASCVD) events.

According to nutritional guidelines of the AHA and the ACC, a heart-healthy lifestyle includes a diet that is rich in vegetables, fruits, whole grains, legumes, non-tropical vegetable oils, and healthy proteins.^2,3 These guidelines also recommend limiting the intake of sweets, sugar-sweetened beverages, and red meat. Caloric requirements should be determined by the need to avoid weight gain, or to lose weight if you are overweight, in order to minimize risk for ASCVD. Physical exercise is also important to heart health and adults generally benefit from 40 minutes of aerobic physical activity three to four times per week.¹

Statins at the highest doses that can be tolerated are strongly recommended for people with very high cholesterol (LDL-C ≥190 mg/dL) between the ages of 20 and 75 years to lower the risk of future ASCVD events.¹ Statins are also recommended for anyone who has had a heart attack or stroke or has been diagnosed with diabetes. Other drugs have also been shown to reduce LDL-C including ezetimibe and PKSK9 inhibitors. These drugs may be recommended in addition to statins, under certain circumstances.

The amount statins can benefit an individual with high cholesterol depends to some degree on how much the cholesterol levels decline in response to statins.⁴ A reduction of about 40 mg/dL in LDL-C causes a 20% to 25% reduction in heart and blood vessel-related events, such as myocardial infarction (MI), coronary deaths, strokes, and coronary revascularizations, for each year statins are taken. This is true even in people with lower levels of cholesterol to start with. Based on data from the Cholesterol Treatment Trialists (CTT) Collaboration, a meta-analysis of data from 170,000 participants in 26 randomized trials, for each 1% reduction of LDL-C, the risk of ASCVD is reduced by approximately 1%.⁵

To test whether larger reductions of LDL-C could be achieved with higher dosages of statins and whether this would result in an even greater reduction of major vascular events (MVE), scientists within the CTT Collaboration compared data from individuals taking more intensive statin regimens with those taking standard statin regimens (total n=39,612).⁵ Compared with less intensive regimens, more intensive regimens resulted in a 15% (95% confidence interval [CI] [11 – 18], p<0.0001) further reduction in MVE. MVE were defined as coronary deaths, non-fatal MI, coronary revascularization, and ischemic stroke.

The 2018 AHA/ACC cholesterol guidelines also recommend high-intensity statins for adults 40 to 75 years of age with moderately high cholesterol (LDL-C levels 70 mg/dL to 189 mg/dL) at high (>20%) 10-year risk of have a heart attack or stroke. They recommend moderate-intensity statins for adults 40 to 75 years of age at intermediate (≥7.5% and <20%) 10-year risk for heart attack or stroke.¹ The 10-year risk of heart attack or stroke can be estimated using the Pooled Cohort Equation (PCE) that factors in cholesterol levels, age, smoking status, blood pressure levels, and race to predict ASCVD risk. There is an easy-to-use online calculator, ASCVD Risk Estimator Plus, based on the PCE.^6,7 Criticism of the calculator includes that the risk calculator may overestimate risk in some populations, specifically in socioeconomically advantaged individuals.⁸ Furthermore, the equations underlying the risk calculator are based on population level risks, not an individual’s risk.⁶ Nevertheless, the risk calculator does provide a basis to have a discussion with patients about their personal risk.

Muntner et al. assessed the accuracy of the PCE in adults age 45 to 79 years without ASCVD and with LDL-C levels below 190 mg/dL with data from the Reasons for Geographic and Racial Differences in Stroke study.⁶ In 10,997 non-diabetics not taking statins, a population likely to use the PCE, the differences between the observed incidence versus PCE-predicted risk were small. The goal for statin therapy in high-risk individuals recommended by the 2018 AHA/ACC guidelines is a reduction of 50% in LDL-C.¹ The goal in intermediate-risk patients is a reduction of 30%.

Adults who are younger than 40 years of age should consider statins if their LDL-C level is ≥160 mg/dL or if there is a family history of premature ASCVD.¹ Individuals who are over 75 years of age with high cholesterol may also be candidates for statin therapy, but strong evidence of risk and benefits in this age group is lacking.

^References

1. Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol. J Am Coll Cardiol 2018.
2. Eckel R, Jakicic J, Ard, JD et al. 2013 AHA / ACC guideline on lifestyle management to reduce cardiovascular risk. J Am Coll Cardiol 2014; 63 (25).
3. Jensen MD, Ryan DH, Apovian CM, et al. 2013 AHA / ACC / TOS guideline for the management of overweight and obesity in adults. J Am Coll Cardiol 2014; 63 (25): 2985-3023.
4. Collins R, Reith C, Emberson J, et al. Interpretation of the evidence for the efficacy and safety of statin therapy. Lancet 2016; 388 (10059): 2532-2561.
5. Baigent C, Blackwell L, Emberson J, et al. Efficacy and safety of more intensive lowering of LDL cholesterol: A meta-analysis of data from 170 000 participants in 26 randomised trials. Lancet 2010; 376 (9753): 1670-1681.
6. Muntner P, Colantonio LD, Cushman M, et al. Validation of the atherosclerotic cardiovascular disease pooled cohort risk equations. JAMA - J Am Med Assoc 2014; 311 (14): 1406-1415.
7. ASCVD Risk Estimator Plus. American College of Cardiology. 2017; http://tools.acc.org/ASCVD-Risk-Estimator-Plus/#!/calculate/estimate/. Accessed 9/20/2019.
8. Colantonio LD, Richman JS, Carson AP, et al. Performance of the atherosclerotic cardiovascular disease Pooled Cohort risk equations by social deprivation status. J Am Heart Assoc 2017; 6 (3).