2018 AHA/ACC Multisociety Cholesterol Guideline vs 2019 ESC/EAS Dyslipidemia Guidelines: 5 Things to Know

Andi Shahu, MD, MHS; David I. Feldman, MD, MPH; Erin D. Michos, MD, MHS, FACC, FAHA, FASE


June 30, 2021

Editorial Collaboration

Medscape &

2. The AHA/ACC and ESC/EAS guidelines have slightly different indications for nonstatin therapy.

Although the AHA/ACC and ESC/EAS guidelines both include statin therapy, ezetimibe, and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors as part of the treatment armamentarium for ASCVD prevention, the ESC/EAS guidelines support more liberal use of nonstatins as add-on therapy. There are several reasons for the difference between the recommendations and approach to nonstatin therapy in the two guidelines, including the cost-effectiveness of nonstatin use in certain populations.

The ESC/EAS guidelines recommend lifestyle modification and statin therapy as initial therapy to achieve a low-density lipoprotein cholesterol (LDL-C) treatment goal that is based on the patient's ASCVD risk status. If these goals are not met and the patient is in fact adherent to maximally tolerated statin therapy and lifestyle modifications, the ESC/EAS guidelines then recommend the addition of ezetimibe and/or a PCSK9 inhibitor in both secondary prevention and high-risk primary prevention based on estimated ASCVD risk.

The AHA/ACC guideline recommends lifestyle modifications for patients at all risk levels. Statin therapy is recommended for patients with known ASCVD (secondary prevention) and in primary prevention for patients with LDL-C ≥ 190 mg/dL, patients 40-75 years of age who have diabetes, and patients deemed to be at significantly elevated ASCVD risk after a clinician-patient risk discussion. A high-intensity statin is recommended for high-risk patients with an estimated 10-year ASCVD risk ≥ 20%. According to the AHA/ACC guideline, at least moderate-intensity statin therapy should be considered for those with an intermediate estimated 10-year ASCVD risk (≥ 7.5% to < 20%) and among selective borderline-risk individuals (10-year risk, 5% to < 7.5%), particularly in the presence of risk enhancers.

High-intensity statins are recommended for all patients with clinical ASCVD and for those with severe primary hypercholesterolemia. Patients with diabetes should be treated with at least a moderate-intensity statin, and a high-intensity statin should be considered in patients who have diabetes and multiple ASCVD risk factors or who have diabetes-specific risk enhancers. Per the AHA/ACC guideline, ezetimibe and PCSK9 inhibitors are recommended only as additional lipid-lowering therapy for patients with severe hypercholesterolemia or clinical ASCVD. Among secondary prevention patients, the AHA/ACC guideline reserves PCSK9 inhibitors predominantly for patients with ASCVD who are at very high risk and whose LDL-C levels remain above risk thresholds.

3. The two guidelines have different approaches to treatment according to the presence of subclinical atherosclerosis.

As previously noted, the CAC test may be used to identify subclinical atherosclerosis in patients. Growing evidence supports use of a CAC score to help guide decisions regarding utilization of lipid-lowering therapy when treatment decisions are uncertain. According to the AHA/ACC guideline, the CAC score can be used as a risk-decision aid to reclassify primary prevention patients whose 10-year risk for ASCVD is intermediate (7.5%-19.9%) or borderline (5.0%-7.5%) and to help guide decision-making around statin use in primary prevention patients in circumstances wherein there is patient indecision or risk uncertainty. Statin therapy should be initiated in patients with a CAC score ≥ 100; however, patients with a CAC score between 1 and 99 are considered likely to benefit from statin therapy, especially if they are older than 55 years. When CAC is absent (score of 0) in intermediate- and borderline-risk individuals, statin therapy may be deferred for 3-5 years, given the low likelihood of events in this population. Of note, the ESC/EAS guidelines do not recommend "de-risking" patients whose CAC score is 0.

Similar to AHA/ACC, the ESC/EAS guidelines recommend using the CAC score as a risk modifier for low- and moderate-risk patients (as determined by the SCORE calculator). The two guidelines differ in treatment decisions when significant subclinical atherosclerosis is identified (CAC score > 100). The ESC/EAS guidelines recommend treating these patients more aggressively with statin and nonstatin therapy, if needed, to achieve an LDL-C level < 70 mg/dL.


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