New Hyperlipidemia Guidelines Include Controversial Recommendations, Subjective Risk Tool

DECEMBER 01, 2013
Frank J. Domino, MD

Frank J. Domino, MD


Stone NJ, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. Circulation. 2013 Nov 12.

Study Methods

The American College of Cardiology (ACC) and American Heart Association (AHA) collaborated with the National Heart, Lung, and Blood Institute (NHLBI) and other stakeholders and professional organizations to develop clinical practice guidelines for the assessment of cardiovascular (CV) risk, lifestyle modifications to reduce that risk, and management of blood cholesterol, weight, and obesity in adults.

Results and Outcomes

The report authors developed recommendations and assigned each one an evidence grade, as annotated below.
  1. Patients <75 years old with known atherosclerotic cardiovascular disease (ASCVD) should receive high-intensity statins, such as atorvastatin 40-80 mg/day or rosuvastatin 20-40 mg/day. [A]
  2. Patients >75 years old with known ASCVD may benefit from moderate-intensity statin therapy with atorvastatin 10-20 mg, rosuvastatin 5-10 mg, pravastatin 40-80 mg, simvastatin 20-40 mg, lovastatin 40 mg, fluvastatin 40 mg bid, fluvastatin XL 80 mg, or pitavastatin 2-4 mg, or high-intensity statin therapy. [E]
  3. Patients >21 years old with low-density lipoprotein (LDL) >190 mg/dL or triglycerides >500 mg/dL should be evaluated for secondary causes and receive high-intensity statin therapy. [B]
  4. Patients aged between 40-75 years of age with diabetes whose 10-year CV risk is ≥7.5% should receive high-intensity statins. [E]
  5. Patients aged between 40-75 years of age with diabetes whose 10- year CV risk is <7.5%should receive moderate-intensity statin therapy. [A]
  6. Patients aged <40 or >75 years old with diabetes should consider statin therapy. [E]
  7. Patients aged between 40-75 years old without ASCVD or diabetes with 10-year CV risk of ≥7.5% should receive moderate- to high-intensity statin therapy. [A]
  8. All patients should undergo lifestyle changes consisting of a diet rich in fruit, vegetables, whole grains, fish, low-fat dairy, lean poultry, nuts, legumes, and non-tropical oils, as well as restricted saturated fats, trans fats, sweets, sugar, sweetened beverages, and sodium. All patients should also engage in 40 minutes of aerobic physical activity of moderate to vigorous intensity 3-4 times per week and abstain from tobacco use.
A= Strong evidence to support recommendation, or high certainty based on evidence that net benefit is substantial
B= Moderate certainty based on evidence that net benefit is moderate to substantial, or high certainty that net benefit is moderate
E= Expert opinion, which means “there is insufficient evidence, or evidence is unclear or conflicting, but this is what the Work Group recommends.”


Clinicians should move away from specific cutoffs as goals for treating hyperlipidemia, and instead focus on stratifying patients based upon demographics and CV risk. From those factors, physicians should initiate either high- or moderate-intensity statin therapy, and all patients should engage in aerobic exercise and move from a low-fat diet to a Mediterranean diet, which includes fruits, vegetables, fish, nuts, and non-tropical oils.

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