Aims: The 2013 American College of Cardiology/American Heart Association cholesterol guideline was a major paradigm shift and heavily criticized by some experts. A better understanding of the methodology used to develop the guideline, the guideline recommendations, and the evidence supporting them addresses many of criticisms.
Methods and results: An extensive body of evidence from randomized clinical trials supports the new risk-based approach. The emphasis is on the appropriate intensity of statin therapy in patients most likely to benefit. The National Institute for Health and Care Excellence guidelines have taken a similar approach. Recent studies have found the 2013 guideline outperforms earlier cholesterol guidelines recommending low-density lipoprotein cholesterol (LDL-C) treatment thresholds and targets. The 2013 cholesterol guideline better identifies high-risk patients with a greater burden of atherosclerosis and avoids treating those at lower risk with little atherosclerosis; its application would prevent up to 450 000 more atherosclerotic cardiovascular disease (ASCVD) events over 10 years. The 2013 cholesterol guideline also recommends regularly monitoring LDL-C levels to assess adherence to lifestyle and drug therapy, and adjusting treatment based on response to therapy and adverse events. Non-statins shown to reduce ASCVD events when added to statin therapy, and that have an acceptable margin of safety in randomized, controlled clinical trials, are preferred. Ezetimibe has now been shown to meet this standard.
Conclusions: The concept of net benefit introduced in the 2013 ACC/AHA cholesterol guideline identifies patients most likely to benefit from statin therapy to reduce ASCVD risk. Net benefit, incorporating the absolute ASCVD risk of a patient and the relative reduction in ASCVD risk based on the magnitude of LDL-C reduction from the addition of a non-statin, can be used when considering whether to add ezetimibe or another LDL-C lowering drug.
Keywords: Cardiovascular risk; Cholesterol; Guideline; Primary prevention; Risk assessment; Secondary prevention.
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