How should I manage my cholesterol?

Atherosclerosis begins in young adulthood and develops into atherosclerotic cardiovascular disease (ASCVD) in middle age or later, so you can help your patients reduce their risk of ASCVD by preventing or managing risk factors early in life. For example, young adults who rapidly develop atherosclerosis often have multiple risk factors, such as hypercholesterolemia, hypertension, smoking, diabetes and obesity. The "2018 Blood Cholesterol Management Guidelines" suggest that most of these patients can reduce their lifetime risk of ASCVD through a healthy lifestyle and only select patients with moderately high low-density lipoprotein cholesterol (LDL-C) (≥160 mg/dL) or those with very high LDL-C levels (≥190 mg/dL [≥4.9 mmol/L]) require drug therapy.

ASCVD risk-enhancing factors

For primary prevention, appropriate therapeutic interventions are selected based on the patient's age and health status.

 

Children and adolescents (10-19 years)

For children and adolescents, healthy lifestyle practices are promoted to prevent or reduce ASCVD risk.

For children and adolescents, promote healthy lifestyle practices to prevent or reduce ASCVD risk.

• In patients without cardiovascular risk factors or family history of early cardiovascular disease, youmay measure a fasting lipid profile or nonfasting non–HDL-C once between the ages of 9 and 11 years, and again between the ages of 17 and 21 years, to detect lipid abnormalities (Table 1).

• In obese patients or those with other metabolic risk factors, measure a fasting lipid profile to detectlipid disorders. Encourage your patients with obesity-related lipid disorders to reduce their caloricintake and increase their aerobic activity.

• In patients with a family history of early cardiovascular disease or significant hypercholesterolemia, you may measure a lipoprotein profile when the patient is as young as 2 years old to detect familial hypercholesterolemia (FH) or rare forms of hypercholesterolemia. In those with moderate or severe hypercholesterolemia, screen relatives to identify those with hypercholesterolemia. If patients 10 years or older have an LDL-C level persistently 190 mg/dL (4.9 mmol/L) or higher, or 160 mg/dL(4.1 mmol/L) or higher with FH, and they don’t respond adequately to lifestyle therapy within 6 months, start statin therapy.

Abbreviations: HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol; NCEP, National Cholesterol EducationProgram; TC, total cholesterol.

*Values for plasma lipid and lipoprotein levels are from the NCEP Expert Panel on Cholesterol Levels in Children. Non–HDL-C values from the Boga lusa Heart Study are equivalent to the NCEP Pediatric Panel cutpoints for LDL-C.

The cutpoints for high and borderline high represent approximately the 95th and 75th percentiles, respectively. Low cutpoints for HDL-C represent approximately the 10th percentile.

Young Adults (20-39 Years of Age)

Even moderate hypercholesterolemia can lead to atherosclerosis, so encourage young adults to make lifestyle changes that reduce their risk for hyperlipidemia and associated ASCVD. Along with lifestyle changes, young adults with primary elevations of LDL-C 190 mg/dL or greater may take statins. Stress to young adults that prolonged hyperlipidemia before age 55 increases their risk of coronary heart disease significantly. In addition, an elevated LDL-C that persists after you’ve excluded secondary causes suggests FH, so perform cascade screening to identify other affected family members.

Adults (40-75 Years of Age)

Three major high-risk categories for adults are severe hypercholesterolemia, diabetes, and ages 40 to 75 years.

• For patients with severe hypercholesterolemia (LDL-C levels ≥190 mg/dL [4.9 mmol/L]), begin immediate statin therapy.

• Start adults with diabetes on a moderate-intensity statin, and as they develop multiple risk factors, move up to a high-intensity statin.

• Use the 10-year ASCVD risk to guide your therapeutic considerations for other adults because those with higher estimated ASCVD risk are more likely to benefit from statin treatment. In addition, consider several “risk enhancers” that you can use to initiate or intensify statin therapy. If you can’t determine risk or you find problems with statin therapy, measure coronary artery calcium (CAC) to refine risk assessment.

Older Adults (Older Than 75 Years)

In older adults with an LDL-C level of 70 to 189 mg/dL (1.7-4.8 mmol/L), you may initiate a moderate intensity statin. However, statin therapy may be stopped when the patient’s physical or cognitive functional decline, multimorbidity, frailty, or reduced life expectancy limit the potential benefits. In adults 76 to 80 years of age with an LDL-C level of 70 to 189 mg/dL (1.7-4.8 mmol/L), measure CAC to reclassify those with a CAC score of zero to avoid statin therapy

Lifestyle Therapies

Healthy Diet

The American Heart Association and the American College of Cardiology have long recommended a healthy diet for patients at risk for atherosclerotic cardiovascular disease (ASCVD) and for the general public.

• Vegetables, fruits, and whole grains
• Legumes and nuts
• Low-fat dairy products
• Low-fat poultry (without the skin)
• Fish and seafood
• Nontropical vegetable oils

The 2018 guideline does provide room for cultural food preferences in a healthy diet, but in general, all patients should limit their intake of saturated and trans fats, sweets, sugar-sweetened beverages, and red meats.

Physical Activity

In addition to a healthy diet, all patients should include regular physical activity in their weekly routines, at moderate to vigorous intensity. Any activity is better than nothing, so if your patients can’t meet the recommendation of vigorous activity, moderate-intensity activity can still help them reduce their risk of ASCVD.

Below are the American Heart Association’s recommendations for physical activity per week (preferably spread throughout the week):

For Overall Cardiovascular Health and Lowering Cholesterol

•  Atleast 150 minutes of moderate-intensity physical activity (for example, 30 minutes, 5 days a week)
•  Atleast75 minutes of vigorous-intensity physical activity (for example, 25 minutes, 3 days a week)
• A combination of moderate- and vigorous-intensity aerobic activity
• At least 2 days of moderate- to high-intensity muscle-strengthening activities (such as resistanceweight training) for additional health benefits

Weight Control

It’s important to work with patients to help them reach and maintain a healthy weight (Table 3). You may need to suggest that they adjust their caloric intake to avoid weight gain or, in overweight and obese patients, to promote weight loss.

Body Mass Index

References：

1. High cholesterol - Symptoms and causes - Mayo Clinic

2. High Cholesterol Facts | cdc.gov

See also:

1. Cholesterol care