Management of Blood Cholesterol
Key Points
Key Points
1. Introduction
- In all individuals, emphasize a heart-healthy lifestyle across the life course.
- In patients with clinical ASCVD, reduce low-density lipoprotein cholesterol (LDL-C) with high-intensity statin therapy or maximally tolerated statin therapy.
- In very high-risk ASCVD, use a LDL-C threshold of 70 mg/dL (1.8 mmol/L) to consider addition of nonstatins to statin therapy. Very high-risk includes a history of multiple major ASCVD events or 1 major ASCVD event and multiple high-risk conditions.
- In patients with severe primary hypercholesterolemia (LDL-C level ≥190 mg/dL [≥4.9 mmol/L]), begin high-intensity statin therapy without calculating 10-year ASCVD risk.
- In patients 40 to 75 years of age with diabetes mellitus and LDL-C ≥70 mg/dL (≥1.8 mmol/L), start moderate-intensity statin therapy without calculating 10-year ASCVD risk.
- In adults 40 to 75 years of age evaluated for primary ASCVD prevention, have a clinician-patient risk discussion before starting statin therapy.
- In adults 40 to 75 years of age without diabetes mellitus and with LDL-C levels ≥70 mg/dL (≥1.8 mmol/L), at a 10-year ASCVD risk of ≥7.5%, start a moderate-intensity statin if a discussion of treatment options favors statin therapy.
- In adults 40 to 75 years of age without diabetes mellitus and 10-year risk of 7.5% to 19.9% (intermediate risk), risk-enhancing factors favor initiation of statin therapy.
- In adults 40 to 75 years of age without diabetes mellitus and with LDL-C levels ≥70 mg/dL to 189 mg/dL (≥1.8–4.9 mmol/L), at a 10-year ASCVD risk of ≥7.5% to 19.9%, if a decision about statin therapy is uncertain, consider measuring coronary artery calcium (CAC).
- Assess adherence and percentage response to LDL-C–lowering medications and lifestyle changes with repeat lipid measurement 4 to 12 weeks after statin initiation or dose adjustment, repeated every 3 to 12 months as needed.
Diagnosis
...Diagnosis...
...2. High Bl...
...2.1. Measurements...
...ts who are 20 years of age or olde...
.... In adults who are 20 years of age or older an...
...or patients with an LDL-C level less t...
...dults who are 20 years of age or older...
Treatment
...Treatment...
...3. T...
...owering Drugs Among lipid-lower...
...-, Moderate-, and Low-Intensity Statin T...
...4. Pa...
...4.1. Second...
...ho are 75 years of age or younger wit...
...with clinical ASCVD in whom high-intensity st...
...patients with clinical ASCVD who are jud...
...In patients with clinical ASCVD who are...
...In patients with clinical ASCVD who are on maxima...
Value Statement 6. At mid-2018 list pri...
.... In patients older than 75 years of age with cli...
...older than 75 years of age who are tolerating h...
9. In patients with clinical ASCVD who are recei...
...In patients with heart failure (HF) with reduce...
...erosclerotic cardiovascular disease (ASCVD)...
Figure 1. Secondary Prevention in Patients W...
.... Very High-Riska of Future ASCVD E...
...4.2. Sever...
.... In patients 20 to 75 years of age with a...
...ents 20 to 75 years of age with an LDL-C level of...
...0 to 75 years of age with a baseline LDL-C level...
...patients 30 to 75 years of age with heterozygou...
...ents 40 to 75 years of age with a ba...
...6. Among patients with FH without evidence of cli...
...4.3. Diabetes Mel...
1. In adults 40 to 75 years of age with...
...ts 40 to 75 years of age with diabetes...
...n adults with diabetes mellitus who...
...s older than 75 years of age with diab...
...lts with diabetes mellitus and 10-year ASCVD r...
...der than 75 years with diabetes mellitus...
...adults 20 to 39 years of age with diabetes melli...
...iabetes-Specific Risk Enhancers Tha...
...4.4. P...
...tion and Risk AssessmentModerate intensity generic...
...ry Prevention Figure 2. Primary Prevention...
...sk-Enhancing Factors for Clinician–Patient...
...4.4.2. Primary Preve...
...ults at intermediate-risk, statin therap...
...ermediate-risk patients, LDL-C levels should be r...
...imary prevention of clinical ASCVDa in a...
...s and patients should engage in a risk discuss...
...iate-risk adults, risk-enhancing facto...
...te-risk or selected borderline-risk adult...
...intermediate-risk adults or selected borderl...
...ntermediate-risk adults who would benefit from m...
...n patients at borderline risk, in risk...
...tion of clinical aASCVD includes acute...
Table 5. Checklist for Clinician–Pa...
...le 6. Selected Examples of Candidates for CAC Me...
...4.4.3. Monit...
...to changes in lifestyle and effects of LDL-C–l...
...4.4.4. Primary P...
...4.4.4.1. Older Adults...
...lts 75 years of age or older with an LDL-C l...
...ults 75 years of age or older, it may be reason...
...In adults 76 to 80 years of age with an LD...
...4.4.4.2. Children and Adol...
...In children and adolescents with lipid di...
...hildren and adolescents with lipid abnorma...
...nd adolescents 10 years of age or older with a...
...In children and adolescents with a family history...
...n and adolescents found to have mod...
...ldren and adolescents with obesity or other metabo...
...dren and adolescents without cardiovascular risk f...
Family history of early aCVD is defined here...
...l and Abnormal Lipid Values in Childhooda,b...
...4.5. Other Populations at...
...clinical decision-making in adults o...
.... Racial/Ethnic Issues in Evaluation, Risk...
...4.5.2. Hypertr...
...In adults 20 years of age or older with...
...s 40 to 75 years of age with moderate or s...
3. In adults 40 to 75 years of age with severe...
...ults with severe hypertriglyceridem...
...4.5.3. Issues S...
...hould consider conditions specific to women,...
...hildbearing age who are treated with statin t...
...dbearing age with hypercholesterol...
...4.5.4 Adults With...
...ts 40 to 75 years of age with LDL-C...
...ith advanced kidney disease that requires...
3. In adults with advanced kidney d...
...4.5.5...
1. In adults 40 to 75 years of age with LDL-C 70 t...
2. In patients with chronic inflammatory dis...
...adults with RA who undergo ASCVD risk asse...
...5. Statin Safe...
...clinician-patient risk discussion is reco...
...patients with statin-associated muscle symptoms...
.... In patients with indication for statin the...
...In patients with statin-associated side eff...
.... In patients with increased diabetes mellitus ris...
...atients treated with statins, it is...
...ents at increased ASCVD risk with chro...
8. In patients at increased ASCVD ri...
...zyme Q10 is NOT recommended for routine use in p...
...0. In patients treated with statins, routine meas...
...tatin-Associated Side Effects (SASE) St...
...6. Implementation...
...erventions focused on improving adherence to pr...
...s, health systems, and health plans sh...
...therapy is prescribed, a patient-clini...
...re 3. Cost-Effectiveness Analysis for PCSK9 I...