Journal of Cardiovascular Nursing
Vol. 34, No. 2, pp. 103–105 x Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
Progress in Prevention
New 2018 Cholesterol Guideline
Enhanced Risk Estimation and Therapeutic Options
Drive Shared Decision Making
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Cheryl R. Dennison Himmelfarb, PhD, RN, ANP, FAHA, FPCNA, FAAN;
Lola Coke, PHD, ACNS-BC, RN-BC, FAHA, FPCNA, FAAN
H igh serum cholesterol is a ma-
jor risk factor for cardiovascu-
lar disease (CVD), the leading cause
of death among men and women in
the United States. One in 5 of youths
aged 6 to 19 years has at least 1 abnor-
mal cholesterol measure,1 and almost
half of US adults older than 40 years
are eligible for statin therapy for the
management of high cholesterol.2
In addition, familial hypercholester-
olemia affects up to 1 in 200 individ-
uals; with elevated total cholesterol
and low-density lipoprotein choles-
terol (LDL-C), these individuals have
a 20-fold increased risk of CVD.3
Given the high prevalence and broad
impact on the population, a life course
approach to screening, detection, and
management of cholesterol is neces-
sary to minimize atherosclerotic CVD
Cheryl R. Dennison Himmelfarb, PhD, RN,
ANP, FAHA, FPCNA, FAAN
Professor and Associate Dean for Research,
Johns Hopkins University School of Nursing,
Baltimore, Maryland.
Lola Coke, PHD, ACNS-BC, RN-BC, FAHA,
FPCNA, FAAN
Associate Professor, Rush University Medical
Center, Chicago, Illinois.
The authors have no funding or conflicts of
interest to disclose.
Correspondence
Cheryl R. Dennison Himmelfarb, PhD, RN,
ANP, FAHA, FPCNA, FAAN, Johns Hopkins
University School of Nursing, 525 N Wolfe St,
Rm 420, Baltimore, MD 21205-2110
(cdennis4@jhu.edu).
DOI: 10.1097/JCN.0000000000000563
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
(ASCVD) risk and premature mor-
bidity and mortality.
The American College of Cardi-
ology and American Heart Associ-
ation in partnership with multiple
other professional societies, includ-
ing the Preventive Cardiovascular
Nurses Association, released a new
guideline in November 2018 for cho-
lesterol management in children,
adolescents, and adults.4 This guide-
line reflects new evidence generated
since the last focused guideline was
published in 2013. Key changes in
the new guideline include refinement
of risk assessment with the addition
of other risk-enhancing factors and
coronary artery calcium (CAC) score
as well as selective use of nonstatin
therapies as treatment adjuncts in
secondary prevention.
The new guideline emphasizes re-
ducing lifetime ASCVD risk through
a heart-healthy lifestyle across the life
course. It is recommended to review
lifestyle habits (eg, diet, physical ac-
tivity, weight or body mass index,
and tobacco use), endorse a healthy
lifestyle, and provide relevant advice,
materials, or referrals.
Shared decision making is cen-
tral to the guideline with clinician-
patient risk discussion guided by
assessment of ASCVD risk using the
ASCVD Risk Estimator,5 potential
for ASCVD risk-reduction benefit,
adverse effects, drug-drug interactions,
and patient preferences. The new
guideline establishes the following
10-year ASCVD risk categories: low
risk (<5%), borderline risk (5% to
<7.5%), intermediate risk (7.5% to
<20%), and high risk (20%). For
young adults who are at a low
10-year risk, communication of life-
time ASCVD risk may be helpful in
promoting adherence to healthy life-
style recommendations.
New in this guideline, in addi-
tion to assessment of ASCVD risk,
consideration of other risk-enhancing
factors is recommended to guide
tailoring of treatment decisions es-
pecially among individuals in the
intermediate-risk group. The risk-
enhancing factors, listed in Table 1,
may or may not independently pre-
dict risk in the general population,
but they can be useful in the clinician-
patient risk discussion as specific fac-
tors that influence risk. The presence
of these atherogenic factors in an
individual may help to confirm a
higher risk state and thereby support
a decision to initiate or intensify statin
therapy. Furthermore, when risk sta-
tus is uncertain in adults older than
40 years, a CAC score is an emerging
risk estimation tool to facilitate shared
decision making. Coronary artery cal-
cium measurement may provide a
more precise understanding of risk
and benefit of treatment, particularly
for those at an intermediate risk, and
103
104 The Journal of Cardiovascular Nursing x March/April 2019

4
TABLE 1 Risk-Enhancing Factors for Clinician-Patient Risk Discussion
• Family history of premature ASCVD (male, age < 55 y; female, age < 65 y)
• Primary hypercholesterolemia (LDL-C, 160–189 mg/dL [4.1–4.8 mmol/L); non–HDL-C, 190–219 mg/dL [4.9–5.6 mmol/L])
• Metabolic syndrome (Presence of 3 of the following: increased waist circumference, elevated triglycerides [>175 mg/dL], elevated blood
pressure, elevated glucose, and low HDL-C [<40 mg/dL in men; <50 mg/dL in women])
• Chronic kidney disease (eGFR, 15–59 mL/min per 1.73 m2 with or without albuminuria; not treated with dialysis or kidney transplantation)
• Chronic inflammatory conditions such as psoriasis, rheumatoid arthritis, or human immunodeficiency virus/acquired immunodeficiency syndrome
• History of premature menopause and history of pregnancy-associated conditions that increase later ASCVD risk such as preeclampsia
• High-risk race/ethnicities (eg, South Asian ancestry)
• Lipid/biomarkers: associated with increased ASCVD risk
• Persistently elevated triglycerides, ≥175 mg/dL
• In selected individuals, if measured:
• Elevated high-sensitivity C-reactive protein ≥ 2.0 mg/L
• Elevated Lp(a) ≥ 50 mg/dL or ≥125 nmol/L
• Elevated apoB ≥ 130 mg/dL
• ABI < 0.9

Abbreviations: ABI, ankle-brachial index; apoB, apolipoprotein B; ASCVD, atherosclerotic cardiovascular disease; eGFR, estimated glomerular filtration rate;
HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol; and Lp(a), lipoprotein (a).

select individuals at a borderline risk,
who may be reluctant to initiate or
reinstitute statin therapy. If the CAC
score is zero in these individuals and
there are no higher risk conditions,
statin therapy can be deferred, whereas
a CAC score of 100 or greater favors
statin initiation.
Consistent with the 2013 guide-
line, statins remain the first-line lipid-
lowering agents for ASCVD risk
reduction. The new guideline is con-
sistent in recommending moderate- or
high-intensity statin therapy for the
following groups: (1) clinical ASCVD,
(2) diabetes mellitus with LDL-C of
70 mg/dL or greater, (3) 40 to 75 years
old with LDL-C of 70 to 189 mg/dL
and 10-year ASCVD risk of 7.5%
or greater, and (4) severe hypercho-
lesterolemia (LDL-C  190 mg/dL).
Although magnitude of reduction will
vary by individual, high-intensity statin
therapy typically lowers LDL-C levels
by 50% or greater and moderate-
intensity therapy by 30% to 49%.
For secondary prevention, the guide-
line introduces a threshold of LDL-C
of 70 mg/dL or greater for consider-
ation of newer, nonstatin cholesterol-
lowering agents, including ezetimibe
and PCSK9 inhibitors. Nonstatin
cholesterol-lowering agents will be
mainly limited to secondary preven-
tion in individuals at a very high risk
of new ASCVD events and those who
have had limited response or intol-
erance to statins.
Use of patient education mate-
rials and decision support tools to
promote understanding of ASCVD
risk as well as potential risk reduc-
tion from lipid-lowering therapy can
aid in the clinician-patient risk dis-
cussion. Table 2 provides a variety
of resources to support cholesterol
management efforts, including risk
discussion. Discussion of potential
out-of-pocket cost of therapy to the
patient is essential because of the di-
rect influence on an individual's ability
to adhere to the agreed-upon treat-
ment plan. A teach-back approach
where an individual is encouraged to

TABLE 2 Cholesterol Management Resources for Clinicians and Patients

American Heart Association (AHA)
The AHA provides cholesterol tools and resources for clinicians and patients. “My Cholesterol Guide: Take action. Live Healthy” is
a 21-page patient guide that addresses risk and educates about cholesterol and common medications used to treat hypercholesterolemia
and a lifestyle change treatment plan.6
Preventive Cardiovascular Nurses Association (PCNA)
The PCNA provides cholesterol-related patient resources available including informational tear sheets focused on cholesterol, healthy
lifestyle changes, familial hypercholesterolemia, triglycerides, and lipoprotein(a). In its Heart Healthy Toolbox, there are resources on
healthy eating and choosing dietary fats wisely.7
American College of Cardiology (ACC)
The ACC ASCVD Risk Estimator Plus5 is used by clinicians to estimate cardiovascular risk and support clinician-patient risk discussions.
FH Foundation
The FH Foundation has a comprehensive website to assist clinicians and patients in understanding the diagnosis and management of
familial hypercholesterolemia. It includes screening tools, diagnostic criteria, management plans, and a series of educational pamphlets
for patients and their families.8
Million Hearts
The Million Hearts Initiative dedicated to reducing cardiovascular disease provides clinician and patient resources on cholesterol
management.9
Centers for Disease Control and Prevention (CDC)
The CDC offers clinicians a series of materials on cholesterol management and patient education materials including an animation
library and a communications kit.10

Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.


verbalize what was heard (eg, per-
sonal ASCVD risk, available options,
and risks/benefits) allows a clinician
to address any misunderstanding.
The new 2018 cholesterol guideline
reflects the rapidly evolving science
supporting ASCVD risk estimation
and cholesterol management strategies
across the life course. Implementation
of the guideline to achieve reductions
in CVD morbidity and mortality will
require effective clinician-patient dis-
cussion and shared decision making.
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