The 2018 Cholesterol Management Guidelines: Topics in Secondary ASCVD Prevention Clinicians Need to Know

  • Xiaoming Jia
  • Mahmoud Al Rifai
  • Yochai Birnbaum
  • Sidney C. SmithJr
  • Salim S. ViraniEmail author
Coronary Heart Disease (S. Virani and S. Naderi, Section Editors)
Part of the following topical collections:
  1. Topical Collection on Coronary Heart Disease


Purpose of Review

The 2018 ACC/AHA Multisociety blood cholesterol guidelines provide updated recommendations based on contemporary evidence on the management of serum cholesterol for the prevention of atherosclerotic cardiovascular disease (ASCVD) events. This review discusses clinically important topics in the new guidelines related to secondary ASCVD prevention.

Recent Findings

Since the 2013 ACC/AHA blood cholesterol guidelines, several large randomized control trials involving ezetimibe and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors (evolocumab and alirocumab) have been published. The trials provided evidence that these non-statin, LDL-cholesterol lowering agents are efficacious in reducing risk for ASCVD events in patients with clinical ASCVD. The 2018 guidelines incorporate these new findings into updated clinical recommendations on therapeutic strategies related to the use of ezetimibe and PCSK9 inhibitors. The guidelines also recommend risk stratification of secondary prevention patients to identify those at very high-risk of ASCVD events as these patients would derive the most absolute risk reduction from the addition of non-statin therapies.


While high-intensity statins remain the first-line treatment to prevent recurrent ASCVD events in secondary prevention patients, ezetimibe and PCSK9 inhibitors are evidence-based non-statin agents that can be used when residual on top of maximally tolerated statin therapy in patients deemed to be at very-high risk of recurrent ASCVD events.


Guidelines Cholesterol treatment Secondary prevention Cardiovascular disease 


Compliance with Ethical Standards

Conflict of Interest

Xiaoming Jia, Mahmoud Al Rifai, Yochai Birnbaum, Sidney C. Smith Jr., and Salim S. Virani declare no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

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Copyright information

© This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply 2019

Authors and Affiliations

  • Xiaoming Jia
    • 1
  • Mahmoud Al Rifai
    • 2
    • 3
  • Yochai Birnbaum
    • 4
  • Sidney C. SmithJr
    • 5
  • Salim S. Virani
    • 1
    • 6
    • 7
    Email author
  1. 1.Section of Cardiovascular Research, Department of MedicineBaylor College of MedicineHoustonUSA
  2. 2.Department of MedicineUniversity of Kansas School of MedicineWichitaUSA
  3. 3.Johns Hopkins Ciccarone Center for the Prevention of Heart DiseaseBaltimoreUSA
  4. 4.Section of Cardiology, Department of MedicineBaylor College of MedicineHoustonUSA
  5. 5.Division of Cardiology, Department of MedicineUniversity of North Carolina School of MedicineChapel HillUSA
  6. 6.Health Policy, Quality and Informatics Program, Health Services Research and Development Center for InnovationsMichael E. DeBakey Veterans Affairs Medical CenterHoustonUSA
  7. 7.Section of CardiologyMichael E. DeBakey Veterans Affairs Medical CenterHoustonUSA

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