Summary of key recommendations

Template:Hypercholesterolemia Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

## 2013 Summary of Key Recommendations for the Treatment of Blood Cholesterol to Reduce ASCVD Risk in Adults[1]

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### A. Heart-healthy lifestyle habits should be encouraged for all individuals

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### B. The appropriate intensity of statin therapy should be initiated or continued

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Class I

"1.Clinical ASCVD*

* Age ≤75 y and no safety concerns: High-intensity statin (Level of Evidence: A) "
* Age >75 y or safety concerns: Moderate-intensity statin (Level of Evidence: A) "

"2.Primary prevention – Primary LDL-C ‡190 mg/dL

* Rule out secondary causes of hyperlipidemia (Level of Evidence: B) "
* Age ≥21 y: High-intensity statin (Level of Evidence: B) "

"3.Primary prevention - Diabetes 40–75 years of age and LDL-C 70–189 mg/dL

* Moderate-intensity statin (Level of Evidence: A)  "

"4. Primary prevention – No diabetes 40–75 years of age and LDL-C 70–189 mg/dL

* Estimate 10-y ASCVD risk using the Risk Calculator based on the Pooled Cohort Equationsy in those NOT receiving a statin; estimate risk every 4–6 y (Level of Evidence: B) "
* Re-emphasize heart-healthy lifestyle habits and address other risk factors
* ≥7.5% 10-y ASCVD risk: Moderate- or high-intensity statin (Level of Evidence: A) "

Class IIa

"1.Primary prevention – Primary LDL-C ‡190 mg/dL

* Achieve at least a 50% reduction in LDL-C (Level of Evidence: B) "

"2. Primary prevention - Diabetes 40–75 years of age and LDL-C 70–189 mg/dL

* Consider high-intensity statin when ≥7.5% 10-y ASCVD risk using the Pooled Cohort Equations† (Level of Evidence: B) "

"3. Primary prevention – No diabetes 40–75 years of age and LDL-C 70–189 mg/dL

* 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 (Level of Evidence: C) "
* Re-emphasize heart-healthy lifestyle habits and address other risk factors
* 5 to <7.5% 10-y ASCVD risk: Consider moderate-intensity statin (Level of Evidence: B)  "

Class IIb

"1.Primary prevention – Primary LDL-C ‡190 mg/dL

* LDL-C lowering nonstatin therapy may be considered to further reduce LDL-C (Level of Evidence: C) "

"2.Primary prevention – No diabetes 40–75 years of age and LDL-C 70–189 mg/dL

* Re-emphasize heart-healthy lifestyle habits and address other risk factors
* Other factors may be consideredz: LDL-C !160 mg/dL, family history of premature ASCVD, hs-CRP !2.0 mg/L, CAC score ≥300 Agaston units, ABI <0.9, or lifetime ASCVD risk (Level of Evidence: C) "

"3.Primary prevention when LDL-C <190 mg/dL and age <40 or >75 y, or <5% 10-y ASCVD risk

* Statin therapy may be considered in selected individuals‡ (Level of Evidence: C) "

Class III

"1.Statin therapy is not routinely recommended for individuals with NYHA class II-IV heart failure or who are receiving maintenance hemodialysis "

### C. Regularly monitor adherence to lifestyle and drug therapy with lipid and safety assessments

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Class I

"1.Assess adherence, response to therapy, and adverse effects within 4–12 wk following statin initiation or change in therapy

* Measure a fasting lipid panel (Level of Evidence: A)  "
* Do not routinely monitor ALT or CK unless symptomatic (Level of Evidence: A)  "
* Anticipated therapeutic response: approximately ≥50% reduction in LDL-C from baseline for high-intensity statin and 30% to <50% for moderate-intensity statin
* Insufficient evidence for LDL-C or non–HDL-C treatment targets from RCTs (Level of Evidence: B) "

Class IIa

"1.Assess adherence, response to therapy, and adverse effects within 4–12 wk following statin initiation or change in therapy

* Screen and treat type 2 diabetes according to current practice guidelines. Heart-healthy lifestyle habits should be encouraged (Level of Evidence: C) "
* Anticipated therapeutic response: approximately ≥50% reduction in LDL-C from baseline for high-intensity statin and 30% to <50% for moderate-intensity statin
* For those with unknown baseline LDL-C, an LDL-C <100 mg/dL was observed in RCTs of high-intensity statin therapy (Level of Evidence: B) "

Class IIb

"1.Assess adherence, response to therapy, and adverse effects within 4–12 wk following statin initiation or change in therapy

* Less than anticipated therapeutic response
* Increase statin intensity, or if on maximally-tolerated statin intensity, consider addition of nonstatin therapy in selected high-risk individuals∞ (Level of Evidence: C) "

### D. In individuals intolerant of the recommended intensity of statin therapy, use the maximally tolerated intensity of statin

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Class I

"1. If there are muscle or other symptoms, establish that they are related to the statin (Level of Evidence: A) "
Class IIa

"1.For specific recommendations on managing muscle symptoms please click here (Level of Evidence: B)"

*Clinical ASCVD includes acute coronary syndromes, history of MI, stable or unstable angina, coronary or other arterial revascularization, stroke, TIA, or peripheral arterial disease presumed to be of atherosclerotic origin.
†Estimated 10-year or “hard” ASCVD risk includes first occurrence of nonfatal MI, CHD death, and nonfatal and fatal stroke as used by the Risk Assessment Work Group in developing the Pooled Cohort Equations.
‡These factors may include primary LDL-C !160 mg/dL or other evidence of genetic hyperlipidemias; family history of premature ASCVD with onset <55 years of age in a first-degree male relative or <65 years of age in a first-degree female relative; hs-CRP ≥2 mg/L; CAC score ≥300 Agatston units or ≥75th percentile for age, sex, and ethnicity (for additional information, see http://www.mesa-nhlbi.org/ CACReference.aspx); ABI <0.9; or lifetime risk of ASCVD. Additional factors that might aid in individual risk assessment could be identified in the future.
∞High-risk individuals include those with clinical ASCVD, an untreated LDL-C !190 mg/dL suggesting genetic hypercholesterolemia, or individuals with diabetes 40 to 75 years of age and LDL-C 70 to 189 mg/dL.

## References

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1. ↑ 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults. http://ac.els-cdn.com/S0735109713060282/1-s2.0-S0735109713060282-main.pdf?_tid=06f509a0-9c67-11e6-b670-00000aab0f01&acdnat=1477587879_04fcb2e98e9d9b3a556253eefd0247d2 Accessed on October 27, 2016

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