Cholesterol Guidelines: Better to Individualize High Cholesterol Treatment

Given so many guidelines for hyperlipidemia, the best approach is individualizing care, informed by evidence-based treatment recommendations.

Written by Lynne K Schneider PhD

With Neil Stone, MD, and Robert H. Eckel, MD

Since clinicians rely on the most current guidelines to help inform treatment decisions, a challenge arises when there are many sets of guidelines, each presenting different recommendations. Such is the case regarding the management of hyperlipidemia. How might the clinician determine which set of hyperlipidemia treatment guidelines to follow?

A comparative analysis, published in the Journal of the American College of Cardiology,1 reviews the recommendations presented in five recent guidelines issued by high-profile cardiovascular societies:

“Physicians need to understand the evidence basis for and criteria used to develop each guideline before committing to the recommendations of one over another for any particular patient,” said senior author, Neil Stone, MD, the Bonow Professor of Medicine at the Northwestern University Feinberg School of Medicine in Chicago.

Guidelines Varied Based on Criteria Selection and Panel Responsibilities

All of the reviewed guidelines were developed by expert panels who analyzed evidence of studies based on a rigorous set of criteria.1 Where the guidelines begin to diverge, some recommendations are based on separate groups of experts – one who reviewed the evidence while another drafted the actual guidelines (ie, ACC/AHA and VA-DoD), whereas others used a single working group for both tasks (ie, CCS, ESC/EAS, and USPSTF). In addition, the criteria established to determine study inclusion in the evidence analysis differed, as did the approaches to determine the strength of the evidence.1

Dr. Stone and colleagues noted key differences between these five guidelines, particularly in the estimators for 10-year risk of atherosclerotic cardiovascular (ASCVD) events, differences in recommendations for statin intensities/doses, and consideration of safety concerns.1

“We recommend the term ‘intensity’ as the most appropriate terminology for guidelines, as ‘similar doses of different statins may have different intensities as defined by the level of LDL-C reduction,’” said Dr. Stone.

Understanding the determinants behind each guideline’s risk estimators will inform clinical use, as only some but not all the guidelines included ethnicity, smoking status, diabetes, and treatment for hypertension. In addition, the guidelines differed in treatment recommendations for specific patient subgroups, such as the elderly and those with end-stage renal disease.

Similarly, variability in outcome differences between risk estimators influences treatment thresholds in the different guidelines. “While the various guidelines identify different thresholds for when to initiate statin treatment, all guidelines are in agreement that determining high cholesterol treatment decisions should occur only after a joint clinician-patient risk discussion,” said Dr. Stone. told EndocrineWeb.

For Diabetes, Criteria for Initiating Statin Treatment Differ 

“Each of the five guidelines recommends different criteria for initiating statin treatment in patients with diabetes mellitus,” Dr. Stone told EndocrineWeb. For example, the VA/DoD recommends initiating a statin in patients with hypertension and/or in those who smoke.3

In comparison, the ACC/AHA guidelines recommend starting or continuing a statin in a patient aged 40-75 years with an LDL-C level of 70-189 mg/dl, noting that in a patient with a 10-year ASCVD risk of at least 7.5%, a high-intensity statin is reasonable.2 The USPSTF suggests statins should be considered for patients with diabetes who have a 7.5% to 10% 10-year risk, and recommend statin therapy for patients whose 10-year risk is >10%.4,5  

The Canadian Cardiovascular Society recommends statin therapy for any individuals who have diabetes at 40 years of age or older as well as those with microvascular complications, and those at least 30 years of age with a disease duration of at least 15 years.6 Finally, the ESC/EAS guidelines use LDL-C levels to guide initiation of statins—specifically, for patients with LDL-C >100 mg/dl or those with LDL-C of 70 to 100 mg/dl and either end-organ damage or 1 additional ASCVD risk factor.7

Patient-Centered Care for People With Diabetes Needed to Address Hyperlipidemia 

Robert H. Eckel, MD, professor of medicine at the University of Colorado School of Medicine, told EndocrineWeb, “ this review highlighted the similarities and differences between five leading evidence-based cardiovascular treatment guidelines but there are numerous other available guidelines, many of which are also evidence-based.”

While each guideline affords guidance for treatment decisions, Dr. Eckel believes the “optimal care of patients with diabetes should focus on the individual patient’s goals of management, as established by an evidence-based dialogue between patient and provider.” This is consistent with the trend toward patient-centered care that fosters shared decision-making between the patient and the physician.8

Dr. Stone added, “the guidelines are not static, they continue to evolve based on the accumulation of evidence, and this review does not tout one guideline over another, but rather should be viewed as a useful comparative tool.”  

Further, investigation and integration of new data may minimize the current differences between the guidelines—as the authors noted: “Nothing stands still.”

Both Dr. Stone and Dr. Eckel were co-authors of the ACC/AHA lipid guidelines, but none of the authors have any financial conflicts with regard to this paper.


1. Tibrewala A, Jivan A, Oetgen WJ, Stone NJ. A comparative analysis of current lipid treatment guidelines. Nothing stands still. J Am Coll Cardiol. 2018;71(7):794-799.

2. Stone NJ, Robinson JG, Lichtenstein AH, 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. J Am Coll Cardiol. 2014;63(25 Pt B):2889-2914.

3. Downs JR, O’Malley PG. Management of dyslipidemia for cardiovascular disease risk reduction: synopsis of the 2014 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guideline. Ann Intern Med. 2015;163:291-297.

4. Bibbins-Domingo K, Grossman DC, Curry SJ, et al. US Preventive Services Task Force. Statin use for the primary prevention of cardiovascular disease in adults. US Preventive Services Task Force Recommendation Statement. JAMA. 2016;316:1997-2007.

5. Chou R, Dana T, Blazina L, Daeges M, Jeanne TL. Statins for prevention of cardiovascular disease in adults: evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2016;316:2008-2024.

6. Anderson TJ, Gregoire J, Pearson GJ, et al. 2016 Canadian Cardiovascular Society guidelines for the management of dyslipidemia for the prevention of cardiovascular disease in the adult. Canadian J Cardiol. 2016;321263-1282.

7. Catapano AL, Graham I, De Backer G, et al. 2016 ESC/EAS guidelines for the management of dyslipidaemias. Eur Heart J.  2016;37:2999-3058.

8. Tamhane S, Rodriguez-Gutierrez R, Hargraves I, Montori VM. Shared decision-making in diabetes care. Curr Diab Rep. 2015;15(2):112.

Continue Reading

LDL—How Low to Go In People With Diabetes?