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ACC Cholesterol Guidelines

Summary of Major Recommendations for the Treatment of Blood Cholesterol to Reduce ASCVD Risk in Adults

Encourage heart-healthy lifestyle habits for all individuals
Initiate or continue appropriate intensity of statin therapy
Clinical ASCVD*
Age ≤ 75 years and no safety concerns: high-intensity statin (COE = I; LOE = A)
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)
Rule out secondary causes of hyperlipidemia (see Table 6 in full guideline)
Age ≥ 21 years: high-intensity statin (COE = I; LOE = B)
Achieve at least a 50% reduction in LDL-C (COE = IIa; LOE = B)
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)
Moderate-intensity statin (COE = I; LOE = A)
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
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)
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
• ≥ 7.5% 10-year ASCVD risk: moderate- or high-intensity statin (COE = I; LOE = A)
• 5% to < 7.5% 10-year ASCVD risk: consider moderate-intensity statin (COE = IIa; LOE = B)
• 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
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)
Measure fasting lipid levels (COE = I; LOE = A)
Do not routinely monitor alanine transaminase or creatine kinase levels unless symptomatic (COE = IIa; LOE = C)
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)
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)
• Insufficient evidence for LDL-C or non–HDL-C treatment targets from RCTs
• 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
Less than anticipated therapeutic response:
• Reinforce improved adherence to lifestyle and drug therapy (COE = I; LOE = A)
• Evaluate for secondary causes of hyperlipidemia if indicated (see Table 6 in full guideline) (COE = I; LOE = A)
• Increase statin intensity, or if on maximally tolerated statin intensity, consider addition of nonstatin therapy in select high-risk individuals§ (COE = IIb; LOE = C)
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

 

High-, Moderate-, and Low-Intensity Statin Therapy (Used in the RCTs Reviewed by the Expert Panel)*

HIGH INTENSITY MODERATE INTENSITY LOW INTENSITY
Daily dosage lowers LDL-C by approximately ≥ 50% on average Daily dosage lowers LDL-C by approximately 30% to 50% on average Daily dosage lowers LDL-C by < 30% average
Atorvastatin (Lipitor), 40†to 80 mg Atorvastatin, 10 (20) mg Simvastatin, 10 mg
Rosuvastatin (Crestor), 20(40) mg Rosuvastatin, (5) 10 mg Pravastatin, 10 to 20 mg
Simvastatin (Zocor), 20 to 40 mg‡ Lovastatin, 20 mg
Pravastatin (Pravachol), 40(80) mg Fluvastatin, 20 to 40 mg
Lovastatin (Mevacor), 40 mg Pitavastatin, 1 mg
Fluvastatin XL (Lescol XL), 80 mg
Fluvastatin, 40 mg twice daily
Pitavastatin (Livalo), 2 to 4 mg

 

Flow Chart for treatment

Major Recommendations for Statin Therapy for ASCVD Prevention

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