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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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