Encourage heart-healthy lifestyle habits for all individuals |
Initiate or continue appropriate intensity of statin therapy |
Clinical ASCVD* |
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Age ≤ 75 years and no safety concerns: high-intensity statin (COE = I; LOE = A) |
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Age > 75 years or safety concerns: moderate-intensity statin (COE = I; LOE = A) |
Primary prevention: primary LDL-C ≥ 190 mg per dL (4.92 mmol per L) |
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Rule out secondary causes of hyperlipidemia (see Table 6 in full guideline) |
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Age ≥ 21 years: high-intensity statin (COE = I; LOE = B) |
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Achieve at least a 50% reduction in LDL-C (COE = IIa; LOE = B) |
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Consider LDL-C–lowering nonstatin therapy to further reduce LDL-C (COE = IIb; LOE = C) |
Primary prevention: persons 40 to 75 years of age with diabetes mellitus and with LDL-C of 70 to 189 mg per dL (1.81 to 4.90 mmol per L) |
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Moderate-intensity statin (COE = I; LOE = A) |
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Consider high-intensity statin when ≥ 7.5% 10-year ASCVD risk using the Pooled Cohort Equations† (COE = IIa; LOE = B) |
Primary prevention: persons 40 to 75 years of age without diabetes and with LDL-C of 70 to 189 mg per dL |
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Estimate 10-year ASCVD risk using the risk calculator based on the Pooled Cohort Equations† in those not receiving a statin; estimate risk every 4 to 6 years (COE = I; LOE = B) |
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To determine whether to initiate a statin, engage in a clinician-patient discussion of the potential for ASCVD risk reduction, adverse effects, drug-drug interactions, and patient preferences (COE = IIa; LOE = C) |
Reemphasize heart-healthy lifestyle habits and address other risk factors |
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• ≥ 7.5% 10-year ASCVD risk: moderate- or high-intensity statin (COE = I; LOE = A) |
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• 5% to < 7.5% 10-year ASCVD risk: consider moderate-intensity statin (COE = IIa; LOE = B) |
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• Other factors may be considered‡: LDL-C ≥ 160 mg per dL (4.14 mmol per L), family history of premature cardiovascular disease, high-sensitivity C-reactive protein ≥ 2 mg per L (19.05 nmol per L), coronary artery calcium score ≥ 300 Agatston units, ankle-brachial index < 0.9, or elevated lifetime ASCVD risk (COE = IIb; LOE = C) |
Primary prevention when LDL-C < 190 mg per dL and age < 40 or > 75 years, or < 5% 10-year ASCVD risk |
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Statin therapy may be considered in select individuals‡ (COE = IIb; LOE = C) |
Statin therapy is not routinely recommended for individuals with New York Heart Association class II to IV heart failure or who are receiving maintenance hemodialysis |
Regularly monitor adherence to lifestyle and drug therapy with lipid and safety assessments |
Assess adherence, response to therapy, and adverse effects within 4 to 12 weeks following statin initiation or change in therapy (COE = I; LOE = A) |
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Measure fasting lipid levels (COE = I; LOE = A) |
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Do not routinely monitor alanine transaminase or creatine kinase levels unless symptomatic (COE = IIa; LOE = C) |
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Screen and treat type 2 diabetes according to current practice guidelines; heart-healthy lifestyle habits should be encouraged to prevent progression to diabetes (COE = I; LOE = B) |
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Anticipated therapeutic response: approximately ≥ 50% reduction in LDL-C from baseline for high-intensity statin and 30% to < 50% for moderate-intensity statin (COE = IIa; LOE = B) |
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• Insufficient evidence for LDL-C or non–HDL-C treatment targets from RCTs |
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• For those with unknown baseline LDL-C, an LDL-C < 100 mg per dL (2.59 mmol per L) was observed in RCTs of high-intensity statin therapy |
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Less than anticipated therapeutic response: |
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• Reinforce improved adherence to lifestyle and drug therapy (COE = I; LOE = A) |
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• Evaluate for secondary causes of hyperlipidemia if indicated (see Table 6 in full guideline) (COE = I; LOE = A) |
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• Increase statin intensity, or if on maximally tolerated statin intensity, consider addition of nonstatin therapy in select high-risk individuals§ (COE = IIb; LOE = C) |
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Regularly monitor adherence to lifestyle and drug therapy every 3 to 12 months after adherence has been established; continue assessment of adherence for optimal ASCVD risk reduction and safety (COE = I; LOE = A) |
In individuals intolerant of the recommended intensity of statin therapy, use the maximally tolerated intensity of statin (COE = I; LOE = B) |
If there are muscle or other symptoms, establish that they are related to the statin (COE = IIa; LOE = B) |
For specific recommendations on managing muscle symptoms, see Table 8 in full guideline |
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