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
...agnosis...
...od Cholesterol and ASCVD...
...Measurements of LDL-C and Non–HDL...
1. In adults who are 20 years of a...
...adults who are 20 years of age or older and in wh...
...ients with an LDL-C level less than 70...
...ho are 20 years of age or older and wi...
Treatment
...reatme...
3. Therapeutic Modal...
...pid-Lowering Drugs Among lipid-loweri...
...gh-, Moderate-, and Low-Intensity Stat...
...Patient Management Grou...
...Secondary ASCVD Prevent...
1. In patients who are 75 years of...
...with clinical ASCVD in whom high-in...
...with clinical ASCVD who are judged to...
...nts with clinical ASCVD who are judged...
...tients with clinical ASCVD who are on ma...
...lue Statement 6. At mid-2018 list prices, PCSK9...
.... In patients older than 75 years of ag...
...older than 75 years of age who are tole...
...In patients with clinical ASCVD w...
...patients with heart failure (HF) with reduced...
...therosclerotic cardiovascular disease (ASCVD) in...
...gure 1. Secondary Prevention in Patients With C...
.... Very High-Riska of Future ASCVD EventsHa...
...evere Hypercholesterolemia (LDL-C ≥19...
...0 to 75 years of age with an LDL-C level of 190 mg...
...n patients 20 to 75 years of age with...
...ents 20 to 75 years of age with a baseline LDL-C...
...n patients 30 to 75 years of age with heterozy...
...n patients 40 to 75 years of age with a...
...alue Statement:6. Among patients with F...
...3. Diabetes Mellitus i...
...s 40 to 75 years of age with diabetes mel...
...0 to 75 years of age with diabetes mellitus and a...
3. In adults with diabetes mellitus who h...
4. In adults older than 75 years of age with diabe...
5. In adults with diabetes mellitu...
...s older than 75 years with diabetes mellitus...
...ults 20 to 39 years of age with diabetes mel...
...es-Specific Risk Enhancers That Are Independe...
...mary Prevention...
....4.1. Evaluation and Risk Assessment...
...ure 2. Primary PreventionFigure 2. Prima...
...nhancing Factors for Clinician–Pat...
4.4.2. Primary Prevention Adults 40 to...
...adults at intermediate-risk, statin therapy reduce...
...mediate-risk patients, LDL-C levels...
...the primary prevention of clinica...
...d patients should engage in a risk dis...
...diate-risk adults, risk-enhancing factors favor...
...ermediate-risk or selected borderline...
...termediate-risk adults or selected borderline-risk...
...termediate-risk adults who would benefit from...
...tients at borderline risk, in risk discussi...
...inical aASCVD includes acute coronary synd...
...5. Checklist for Clinician–Patient Sha...
Table 6. Selected Examples of Candidates fo...
...ring in Response to LDL-C–Lowering The...
...to changes in lifestyle and effects...
...ary Prevention in Other Age Groups...
...4.1. Older Adults Additional recommendations f...
...In adults 75 years of age or older wi...
...In adults 75 years of age or older, it may be r...
...6 to 80 years of age with an LDL-C level...
...4.2. Children and Adol...
...dren and adolescents with lipid dis...
...and adolescents with lipid abnormalit...
...children and adolescents 10 years of age or ol...
.... In children and adolescents with a family...
...ldren and adolescents found to have mo...
6. In children and adolescents with obesity...
...n children and adolescents without cardiovas...
...tory of early aCVD is defined here as MI,...
...rmal and Abnormal Lipid Values in Childhooda,bH...
....5. Other Populations at Ris...
...city1. For clinical decision-making in adults o...
...ial/Ethnic Issues in Evaluation, Ri...
...pertriglyceridemia...
...In adults 20 years of age or older with...
.... In adults 40 to 75 years of age with moderate...
.... In adults 40 to 75 years of age with...
...adults with severe hypertriglycer...
....3. Issues Specific to Wo...
...nicians should consider conditions...
...of childbearing age who are treated with stati...
...n of childbearing age with hypercholester...
4.5.4 Adults With...
...In adults 40 to 75 years of age wit...
...s with advanced kidney disease that requires...
...h advanced kidney disease who require d...
...dults With Chronic Inflammatory Disorders...
...n adults 40 to 75 years of age with LDL-C 70...
...with chronic inflammatory disorders or...
...dults with RA who undergo ASCVD risk assessme...
...and Statin-Associated Side Effects...
...cian-patient risk discussion is recommended be...
...with statin-associated muscle symptoms...
...with indication for statin therapy, identifica...
...In patients with statin-associated si...
...atients with increased diabetes mellitus risk or n...
...ients treated with statins, it is recommended...
...tients at increased ASCVD risk with chronic...
...atients at increased ASCVD risk with severe sta...
...0 is NOT recommended for routine use in p...
...nts treated with statins, routine measurements of...
...in-Associated Side Effects (SASE)Hav...
...Implementatio...
...ns focused on improving adherence to prescribed t...
...nicians, health systems, and health...
...apy is prescribed, a patient-clinician discus...
...Cost-Effectiveness Analysis for PCSK9 Inh...