Atherosclerotic cardiovascular disease (ASCVD) is a disease in which plaque, made up of fat, cholesterol, calcium, and other substances, builds up inside your arteries. Over time, the plaque will block the flow of oxygen-rich blood to your organs and other parts of your body leading to serious problems, including heart attacks and strokes. The primary treatment for high blood cholesterol and atherosclerosis is lifestyle changes, the most important include:
1. Adhering to a heart-healthy diet
2. Regular exercise habits
3. Maintenance of a healthy weight
4. Avoidance of tobacco and alcohol products
However, you may need medications if lifestyle changes are not enough. The most important drug therapy being a class of medications called “statins.”
Recently, there was an update of the recommendations for the treatment of blood cholesterol to reduce ASCVD risk. For this guideline, ASCVD includes coronary heart disease, stroke, and peripheral arterial disease, all of presumed atherosclerotic origin. The new guidelines are intended to provide evidence-based recommendations to determine who should get statin therapy and the appropriate statin therapy intensity.
What are the Important Questions?
#1 – Which groups of people would most likely benefit from statin therapy?
#2 – How can we determine someone’s 10-year ASCVD risk, in order to identify higher risk people for statin therapy?
#3 – What is the appropriate “statin” and what are the low-density lipoprotein (LDL) cholesterol goals?
What are the Recommendations?
#1 – Identifying Four Statin Benefit Groups
Group 1: People with known ASCVD (including previously diagnosed myocardial infarction or “heart attack,” coronary heart disease, stroke, or peripheral arterial disease, all of atherosclerotic origin)
For “primary” prevention (people without ASCVD, in order to prevent the disease):
Group 2: ≥21 years old with LDL ≥190 mg/dL (≥4.9 mmol/L)
Group 3: 40-75 years old with LDL 70-189 mg/dL (1.8-4.8 mmol/L) and diabetes
Group 4: 40-75 years old with LDL 70-189 mg/dL (1.8-4.8 mmol/L) and no diabetes, but a greater than 7.5% 10-year ASCVD risk (see #2 – Estimating a 10-year ASCVD Risk)
#2 – Estimating a 10-year ASCVD Risk
In “primary” prevention, the use of a new calculator to estimate 10-year ASCVD risk (including the risk of first nonfatal myocardial infarction or “heart attack,” coronary heart disease death, nonfatal or fatal stroke) is now recommended:
For people in Group 4, this new calculator identifies high risk people for statin therapy.
#3 – Identifying the Intensity of Statin Therapy and Specific LDL Cholesterol Goals
1. When statin therapy is started, most people should be on a moderate-intensity* or high-intensity* statin.
*Moderate-Intensity Statin Therapy
Atorvastatin 10-20 mg
Rosuvastatin 5-10 mg
Simvastatin 20-40 mg
Pravastatin 40-80 mg
Lovastatin 40 mg
Fluvastatin XL 80 mg
Pitavastatin 2-4 mg
*High-Intensity Statin Therapy
Atorvastatin 40-80 mg
Rosuvastatin 20-40 mg
2. Once statin therapy is started, there are no longer any specific LDL cholesterol goals.
3. Nonstatin cholesterol-lowering medications, if added to statin therapy, are no longer recommended due to lack of additional ASCVD risk reduction.
What is the Controversy?
The new guidelines created substantial confusion, controversy, and debate among healthcare providers, patients, and the media. One of the major changes was just being on a statin, if determined to be beneficial, rather than an emphasis on specific LDL cholesterol targets or goals. So, the “treat to target” or “lower the LDL the better” approach to blood cholesterol management is no longer recommended.
Additionally, there has been concern that many people who were not on a statin previously will now be prescribed a statin—thus, dramatically increasing the total number of people taking a statin. This is true. However, cardiovascular disease is the world’s biggest killer so anything we can do to prevent or treat cardiovascular disease will save countless lives and precious healthcare resources.
The thoroughness and strong evidence-based foundation of these recommendations leave little doubt that if you are in one of the four statin benefit groups then statin therapy should be considered.
What You Need To Know
1. Adhere to a heart-healthy lifestyle!
2. Statin therapy is recommended for groups of people proven to have a benefit.
3. Statin therapy is safe when used in properly selected people and appropriately monitored.
4. Engage in a doctor-patient discussion before initiating statin therapy.
Decisions about high blood cholesterol management should carefully consider all the characteristics and circumstances of each individual person. For all people with high blood cholesterol, the benefits of a healthy diet, regular exercise, weight control, and avoidance of tobacco products cannot be overemphasized. Take control of your health!
I am an 83 yr old FL Pharmacist PS6830 Visited my physician last year for check up and blood lab and it had been 13 years. Waste of time as they got it mixed with my son, Jr. I have visited the Winn Dixie Screening for cholesterol , etc (Finger stick fasting for 12 hours) last two times 105 Total cholesterol Very few clinical studies on the internet about low cholesterol. At my age probably should not be concerned. Are there sites about low cholesterol? I have told my friend Jeff Scott who owns one of the largest drugstores and appliances in North Floridam Cheek and Scott Drugs, about your site
Thank you very much for your comment and recommending the site to your friends. You are correct, there is not a lot of information out there about low blood cholesterol. However, the PCSK9 inhibitors are a new class of drugs that have been shown to dramatically lower LDL cholesterol levels – so we are learning more about dramatic cholesterol lowering. As an interesting note, when you are born your LDL cholesterol is 40, and many experts believe that to be the optimum value for heart health (although, no rigorous scientific data to support that claim). PCSK9 inhibitors get LDL cholesterol to those levels, so we are eagerly awaiting data on clinical outcomes – probably in 2017.
I can never complete the 10 year risk assessment, always receive the following error:
Error: valid Total Cholesterol range is 130 to 320 (mg/dL)
My total cholesterol is over 430, LDL is 330. Has always been high; can’t take statins, family history exists. Up side is low blood pressure, no diabetes, and stable weight w/exercise – no inflammation or calcium scoring. My cardiologist scratches his head all the time! Thanks for the update.
Yes, the 10-year ASCVD risk calculator does not apply to you. You would automatically fall into the Group 2 Statin Benefit Group (≥21 years old (I assume) with LDL ≥190 mg/dL). You would benefit from the addition of a statin, but from your comment, it sounds like you can’t take a statin.
Based on your numbers, I would be concerned for familial hypercholesterolemia. Because of this, and your intolerance to statins, the new PCSK9 inhibitors (alirocumab, evolocumab) may be appropriate for you.
You should discuss this information in more detail with your cardiologist. Thank you so much for the comment!
Great article, great site!!!!
I’m 61, white male, 15 lbs overweight and I just had a stent placed in my circumflex artery due to an 80% blockage. My latest bloodwork is: HDL 43, Calculated LDL 119, Total Cholesterol 180.
There is no history of CAD in my family history. My nuclear stress test last year showed no blockages but a cardiac calcium scan showed some calcium buildup and a score of 229.
My cardiologist asked to do a heart cath because my blood pressure was fluctuating to the high side (180/110) for no reason and I’ve had some chest pain on and off for 20 years. My usual BP is 134/82.
Would I benefit from using the 10-year ASCVD risk calculator?
Also, do I have anything to worry about now that I have a stent and should I even have had the stent at all?
Could getting my LDL down and my HDL up have erased the blockage?
Thanks,
John
To answer your question, no, you would not benefit from using the 10-year ASCVD risk calculator. You actually already fall within “Group 1” of the four statin benefit groups (see in the article above), meaning, you would benefit from the addition of a statin to your medical regimen because you already have ASCVD. In your case, you have coronary artery disease as indicated by your recent coronary angiogram and coronary stenting procedure (80% blockage in your left circumflex artery). There is nothing to worry about with your stent, if properly placed, it is now a permanent fixture in your heart artery. Generally speaking, coronary artery blockages of >70% are usually stented, so it seems that your stent was appropriately placed. There is evidence that decreasing your LDL and increasing your HDL with lifestyle changes and/or statin medications will indeed reduce/erase the blockage or plaque burden within your coronary arteries. This should encourage you to take control of your health in an effort to prevent another obstructive blockage in your heart arteries. Thank you very much for your comment and kind words!
Thanks so much Dr. Jason.
One more question please.
I’m now on Lipitor, a baby aspirin and Effient. After a period of time, how will my cardiologist determine that my other minor plaque buildups are gone and if the stent looks normal in function?
Also, the idea of a blood clot due to the stent scares the daylights out of me.
Thanks,
John
Your current medical regimen, along with the suggested lifestyle changes from your doctor and myheart.net (https://myheart.net/articles/10-lifestyle-habits-of-super-heart-healthy-people), will most likely keep your minimal residual burden of coronary artery disease in-check for the foreseeable future. We do not perform routine imaging or stress testing for surveillance of coronary artery disease progression in asymptomatic patients, however, if you ever develop symptoms that could be associated with your heart then further evaluation may be warranted at that time. With regards to your stent, if properly placed at the time of the procedure (and I’m sure it was) your stent should function normally and will not need to be routinely monitored. You must remain on aspirin AND Effient (in your case) for at least 12 months and sometimes longer to prevent small blood clots from forming inside the stent, which is a serious complication from a stenting procedure. If you follow your doctors advice and take your medications as directed, then you should be fine. Thank you for your question!
There is not significant evidence showing that statins actually reduce or erase blockages. Include the horrific side effects and you have a bogus approach to heart disease. Furthermore, the diet is probably doing more to lowering the heart risk than the statins.
There is more rigorous scientific evidence showing the benefit of stains with regards to heart disease, that it is completely undeniable. Not believing in the cardiovascular benefit of stains, at this point in medicine, is complete ignorance. Now, just like with any medication, there are side effects. In most cases these side effects can be managed, and if not, then PCSK9 inhibitors are viable options for patients at high-risk for adverse cardiovascular events. Statins are always combined with lifestyle modifications (e.g. diet and exercise), that goes without saying. And, it is true, if you had an optimal diet and exercise regimen your whole life then you would likely never need a statin – but that is unfortunately not true for the majority of people in the world.
Excellent site! Although I am under the care of a cardiologist, the explanation here was crystal clear and has really helped me understand my case better. My question relates to the use of statin as predicted by your site for my case versus my doctor’s recommendation. My lipid profile is LDL=92,HDL=38,Total=145,TriG=125. I have been on Simvastatin 20 mg for the past several years. However, recently I underwent a stress test and the imaging showed a mild abnormality though the exercise EKG was normal. Since I was suffering from acid reflux and atypical chest pain, they recommended a cath. The angiogram revealed normal arteries except for “very mild atherosclerosis with 20% discrete stenosis and no associated calcification in mid-LAD”. My statin has been changed to Atorvastatin 40 mg and I am on aspirin as well. When I use the risk calculator, it recommends that I should not be on a statin since my 10-year risk is low. Does the “very mild atherosclerosis” put me in Group 1 (coronary artery disease), which qualifies me for a high-intensity statin? I would have thought I would still be in the moderate-intensity statin group. My doctors say my condition is normal for my age (50 years) and that I don’t have CAD as yet.
Thank you very much for your kind words. Yes, you do indeed fall into “Group 1,” so you would benefit from the addition of a high-intensity statin to your medical regimen. Based on your heart catheterization, you do have coronary artery disease (CAD). CAD is not necessarily “normal” for individuals in their early 50s, so it needs to be taken seriously and treated appropriately. The 20% stenosis or blockage is considered non-obstructive CAD (i.e under the umbrella of ASCVD), so a statin (in addition to lifestyle changes) should be used to prevent the progression or reverse your 20% stenosis or blockage. I hope this helps clarify and thank you for your comment!
Thank-you for your response once again. Yes – I am continuing with the statin therapy, which has worked very well for me. At age 35, without a statin, my lipid panel readings were (Total=253,LDL=172,HDL=37,TriG=202), which put me at high-risk. I did not have the benefit of a useful site like this at the time in the late 90’s, but was told they were dangerously high. After being on statin for 16 years (40 mg Lipitor or 40 mg Simvastatin), my average levels are (Total=145,LDL=92,HDL=38,TriG=125), which is a big improvement. I have been asked to continue using the statin and aspirin (81 mg) daily. I did clarify regarding the term “normal”. According to cardiologists, majority of the people over 50 have some atherosclerosis. 20% stenosis is a minimal irregularity and requires statin/aspirin therapy and life-style changes as you suggest. They said this was detectable only because an invasive angiogram was done – all other tests (stress, NM SPECT scan, EKG, echo) are normal. Most people who get angiograms have some irregularity. However, they do not have a control group of normal people with no risk factors who have angiograms done to compare against (the cath, which is most accurate, is also highly invasive and had me quite worried). I hope this can be reversed (or at least stopped). Since I have been taking a statin for 15 years, have normal cholesterol, and lead a healthy lifestyle, I am wondering whether this small blockage started in my 20’s or 30’s, when my cholesterol levels were high. Unfortunately, I am told that there is no way to monitor the progress of CAD except with an angiogram, except to control it with statins and lead a healthy lifestyle.
In your experience, are there cases of reversal of atherosclerosis with statins? This is an area where I do not have much clarity from my doctors.
“According to cardiologists, majority of the people over 50 have some atherosclerosis.” That is incorrect. Cardiologists are notorious for speaking in hyperbole and it does our patients a disservice. In 2010, the prevalence of coronary heart disease was greatest among persons aged ≥65 years (19.8%), followed by those aged 45-64 years (7.1%), and those aged 18-44 years (1.2%). Admittedly, there are several limitations to these statistics from the CDC. However, for your age, 7.1% is a far cry from >50%. This is not meant to scare you, just underscore that coronary heart disease needs to be taken seriously and treated appropriately, it is not “normal.” Most people who have coronary angiography do have some irregularity, but that is because they had the angiogram for a reason. If you did coronary angiography on every single person in the US, the majority would have no atherosclerosis, as you suggested. Once again, not trying to scare you, just putting your heart disease into perspective. Yes, medical therapy (statins, etc.) and lifestyle changes absolutely reverse or halt the progression of CAD. However, it is a disease of aging (as the CDC statistics suggest), so even optimal medical and lifestyle therapies don’t guarantee freedom from obstructive CAD in the future. You can definitely improve you chances by taking care of yourself, and I suggest following our “10 Lifestyle Habits” to keep you on that path: https://myheart.net/articles/10-lifestyle-habits-of-super-heart-healthy-people/. Thanks again for your comment!
Thank-you once again for the clarification. This is excellent information in a detail that I had hoped to get from my doctors. Also, happy to note that I am meeting almost all of the 10 lifestyle changes (short on sleep and exercise on some days). I appreciate your perspective on the atherosclerosis. My doctors and the cardiologists have repeatedly said it is “very, very mild” perhaps based on what they saw of the angiogram (I don’t have an actual report or scan). But they have me on high-intensity statin and aspirin, so it is consistent with what this site and you recommend, although their view is different.
I am actually grateful to the holder of this website who has shared this wonderful paragraph at here.
If I had a heart CT calcium scan in 2009 with the score being a 0 which they tell me is really good for a 39 year old now 45. When should I get another one? My chol is controlled by stains but has never been higher than 240. However with Lipitor it stays around 140 with HDL 38 and LDL 70
Calcium scores should be used, if needed, to risk stratify patients for the use of statins. Since you are on a statin and doing well, there would be no need to repeat the calcium score. At this time, you should continue taking all your medications as prescribed and continue a heart-healthy lifestyle. If you ever have heart trouble (chest pain, shortness of breath, reduced exercise tolerance, etc.) in the future, you should be evaluated by a physician, and at that time a CCTA (coronary CT angiography) or other stress testing modality could be used to evaluate your symptoms. Thank you very much for your question!
In fact no matter if someone doesn’t understand
after that its up to other viewers that they will help, so here it takes place.
thanks for all the info Dr. I havent gone to Drs much in last 10 yrs except for chol therapy (fam history). I’m about 285 total uncorrected chol, down to 135 total on crestor, triglycerides not a problem). went to Dr for 1st time since emergency appendix surgery in March. ran out of crestor after surgery and didnt get back on them (was on for 4 yrs) but always do quarterly tests which levels going back up after being off the statins.
got a new Dr as other one retired and did chol, trig and hs CRP beforehand. total was 263, tri’s still good, hsCRP <0.05. he had me do a calcium test and I almost lost it when it showed a 385 total w/LAD being 375 of that (others <5). some genius decided to tell me all calcium was in widowmaker LAD. am going back to Dr tomorrow and am scared stiff. I'm 59 but been very athletic most of life (except btw 33-40) did triathlons and currently do crossfit 2x-3x a week depending on travel and still outlift all these 20- and 30-somethings altho by stamina has flagged recently a little.
I really worried about this, so worried I updated my will today and made kids aware of where everything could be found if something occurred which kinda freaked them out bc I wouldnt discuss anything until I'm sure of whats up. Guessing I'm a prime candidate for a stent depending on blockage to be done fairly quickly. I'm 59, 5'8" and 185#. dont run much anymore to run but do crossfit 2-3x a week. no chest pain but no more sub 6 min race mikes either. its more like 9 mins now. I almost dont want to admit it but am really worried. kids would be well provided for but I'm looking forward to another 10yrs of work (for what I make retirement would be dumb) and another 15-20 after that of relaxation. amI overreacting or what? thanks.
I understand your concern, especially since you have been healthy and active for most of your life. A coronary artery calcium (CAC) score of 101-400 implies at least moderate atherosclerotic plaque formation with a moderate likelihood that significant coronary artery narrowing is possible. It is not a certainty that you have a blockage in your coronary artery, but a possibility. It is possible, given the fact that you are without symptoms and so active, that you don’t have any significant blockages. However, the test has been ordered and you have the results in hand, so now you and your physician are left with what to do with the information moving forward. I would suggest an exercise stress test with perfusion imaging or if you decide on a left heart catheterization, have the blockage assessed via a fractional flow reserve (FFR) measurement (only if the blockage is of questionable significance by visual inspection). Either of these tests would provide incremental information about the hemodynamic significance of any blockages, if present. Fixing a coronary blockage that has minimal or no hemodynamic consequence would not provide you any benefit, especially if you are not having any chest pain. This is an important decision that you and your physician need to make together.
I have a calcium score of 19. I am 70, female, overweight, with an up to 50% blockage in the LAD.
I have svt and have had an ablation. My cholesterol readings are reasonbly high. I have RA and MS. I have severe atrophy of gluteus medius and gluteus minimus with tendonopathy and tearing. I am told I will need a hip replacement. I have been taking Crestor 5mg. for about c 12 years. Could this have contributed to the muscle wasting? If so should I stop it. I have stopped it previously and my cholesterol increases.
It is unlikely that the Crestor contributed to your muscle wasting. I would not recommend stopping your statin. If anything, the dose should be increased as high-intensity statin therapy would be recommended for you (atorvastatin 40-80 mg everyday or rosuvastatin 20-40 mg everyday). Thank you very much for your question!
hi sir i have one probelm that when i check go for check my bp from left hand its alwyas show low or some time normal when i check my righ hand side its show some time normal nd when i had a problem my right hand bp always show high mean if my left side bp is 110/70 then my right side bp is will be 120/80 if my left side bp is 120/80 so then my right side bp goes high 140/90 its hurt me plz tell me why this happen to me nd now a days i have Erectile dysfunction also nd also i have mild mvp with mild MR plz tell me
Discordant blood pressure in your right and left arms could be a sign of vascular disease, however it is usually not painful. Given your constellation of symptoms, you should probably talk to a local physician. Thank you very much for your question!
I have had high cholesterol & high blood pressure as long as I can remember. I also have had a heart murmur & and an irregular heart beat since I was very little. My parents were told I wouldn’t live past 40. I have worked in a factory doing a lot of heavy lifted. The Doctors keep giving me statins & I get serious cramps in my legs that it wakes me at night, crying, . It also has a lot of other bad side effects on me. I am now 83 yrs. old, and I cannot see taking anything that is going to put me in a chair the rest of my life. Can you help me.
Shirley
Dear Sir,
I also am still active in games here at the condo complex where I live. I still do all my own house work, laundry,, grocery shopping & bill paying. I still drive. My hearing is getting a little bit duller, but I only need glasses to read small print. I have some other medical problems, but they have never kept me from doing anything I wanted to. I almost died when I was 5 from Whooping Cough & pneumonia , and had pneumonia every year until they came out with the shot for it. It kept me out of school twice for 6 wks ea.. I also have crohns disease which is in remission. I’ve had every surgery you can think of, except heart, and still only missed approx. 10-15 days of work for about 60 yrs of work. So you can see I’ve been through a lot and I’m still here and going every day. Are statins really necessary at this time in my life. Thanks.
Shirley
That is an excellent question, are statins really necessary at this time in my life (i.e. at 83 years old who appears to be doing relatively well and symptomatic with statins)? I would say, no, a statin is not absolutely necessary at this time in your life. However, I will also say that controlling your blood pressure would be important moving forward. If you wanted to attempt another statin, among individual statins, simvastatin and pravastatin seem safer and more tolerable than other statins (https://www.ncbi.nlm.nih.gov/pubmed/23838105).
I am 61 year old female, have a BMI of 32, not as active as I would like due to OA knee and ankle issues, i eat healthily most of the time.
I have total cholesterol of 240, LDL of 137 and HDL 74.
My CTCA showed calcium score 2.2 and 10% blocking in LAD.
The cardiologist would like me to take Crestor 5mg mostly based on cholesterol levels and family history of dad dying at 40 years of age, though he was a smoker, overweight, a stress person, didn’t exercise much and had the old fatty diet of 1960s.
Could I have your advice? Hoping that perhaps Crestor not needed?
With evidence of heart disease on your CCTA, the recommendation for statin therapy would be for secondary prevention. Therefore, a statin would be indicated in your case. I would actually recommend Crestor 20mg once a day. Statins are great medications and generally very well tolerated, so you should feel confident in your cardiologist’s recommendation. Also, continuing your dietary changes and attempting as much structured exercise as possible would also be recommended. Thank you very much for your question!
My sister is 55 years of age, and has a much higher cholesterol than I do with an LDL of 5.3 (Australia) and total cholesterol of 7.6.
She had a calcium scan done, and this showed nil calcium.
Her GP said she is low risk and she doesn’t have to take cholesterol lowering medication. With me, her sister (Tina Skellett) having shown a result of the 10% block in LAD and a score of 2.2, would it be prudent of her to commence a statin in view of her much higher levels. She is quite overweight with BMI of 36, eats badly, doesn’t exercise much, has diagnosed depression and low thyroid which are being treated, and of course our dad’s history of dying at 40 of an MI after having had his first MI at 37. Could you advise please? Is it alright, as her GP seems to think, to not treat her much higher cholesterol because she has not shown any blocking as yet even though her older sister (me) is now I am older and menopausal. She is also not menopausal as yet as we have a late menopause. I was almost 60. Thank you.
She could estimate her own 10-year ASCVD risk using the link in the blog post, just from the information you provided, it is difficult to tell. The 10-year ASCVD risk score would give the best information for determining if she needed a statin or not.
I am curious about your view on treating all diabetics with cholesterol lowering medications. I am 48, female with diabetes, stage 3a kidney disease (improved from 3b) due to recurrent infections, congenital heart disease, history of pulmonary valvuloplasty, close to needing aortic valve replaced. I was actually hospitalized last January with intent to do open heart, and i was discharged saying i could wait another year or two. Something has to be good with me, it is only fair, and that’s my cholesterol is 134, triglycerides 50. So, my endocrinologist told me it is recommended by the American heart association that all diabetics be on cholesterol lowering medication. He wants me to talk to my cardiologist at next check up, which i am already 6 months late on. Last time scared me, i told them they weren’t getting me back for a year. I will go in January.
I feel like i am already on so many medications, why add another if it’s not really needed.
I would assess your risk using the 10-year ASCVD risk calculator, then go from there. Hopefully, your cardiologist will determine your risk and then begin the discussion with you. Ultimately, it will be your decision, but I would hear what he/she has to say.
Thank you!! I will look into the ACVSD 10 year risk, do a little research before my appointment next month. I assume it’s risk factors such as weight, or BMI, smoking, etc. I am small 4’11” 127lbs, but still a little high on the bmi. I have other risk factors such as vasculitis, recurrent severe kidney infections with kidney damage, was 3b, improved a bit to 3a. It will be interesting to hear his opinion. FYI… I have lost 85lbs and was able to reduce the stress on my aortic valve enough to buy me a couple of extra years before replacement. Thank you for your input.