Figuring out who should take a statin, a popular type of cholesterol-lowering medication, used to be easy: If your LDL cholesterol (the “bad” kind) was higher than 100 mg/dL, your doctor was supposed to write you a prescription.

That changed five years ago, when the American Heart Association (AHA) and American College of Cardiology (ACC) issued guidelines that shifted the focus to a risk calculator designed to predict the likelihood of having a heart attack or stroke in the next 10 years. If your risk came up as 7.5 percent or higher, your doctor was supposed to strongly consider giving you a statin.

Now a new update to the guidelines, presented at the 2018 AHA Scientific Sessions, urges doctors to take a more nuanced approach to determining who needs a statin, who doesn’t, and who might need an alternate (or additional) cholesterol-lowering medication such as ezetimibe (Zetia) or a PCSK9-inhibitor like alirocumab (Praluent) or evolocumab (Repatha).

Many critics of the 2013 guidelines complained that the ASCVD Risk Calculator over-estimated heart disease risk. The concern was that it would lead to many people taking statins who didn’t really need these drugs.

Donald Lloyd-Jones, MD, coauthor of the update, acknowledged that some overestimating was possible — but that the reverse was also true: “In patients in groups where they are high socioeconomic status or they’re very engaged with the health care system, [the guidelines] do overestimate risk. But then in other groups that have lower socioeconomic status or diseases like HIV or rheumatoid arthritis, they actually underestimate risk,” he told MedPage Today.

The latest update aims for a better balance by making the risk assessment as personalized as possible. After starting with the same risk calculator, doctors are now urged to talk to patients about “risk-enhancing factors.”

In addition to traditional risk factors like high LDL, high triglycerides, high blood pressure, high blood sugar, and smoking, doctors are now supposed to pay closer attention to family history, ethnicity, metabolic syndrome, chronic kidney disease, chronic inflammatory conditions (including types of arthritis), premature menopause, and a history of pre-eclampsia.

When in doubt about the degree of overall risk, doctors should order a heart scan (coronary calcium scan), which measures calcium-rich plaques in the arteries.

The updated cholesterol guidelines also say that while people who need cholesterol-lowering medication should start with a statin, they may need to switch to a drug in a different class — specifically, ezetimibe, and, if that doesn’t work, a PCSK9 inhibitor.

The update also highlighted the importance of lifestyle changes (diet and exercise) for both prevention and treatment of heart disease. It noted that children as young as age 2 should be tested for cholesterol if they have a family history of high cholesterol or heart disease. Otherwise, children should be first tested between ages 9 and 11.

You can find more information about these cholesterol guideline changes here. If you’re unsure about how this news impacts your own treatment, talk to your primary care physician or a cardiologist.

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