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
...gnosis...
...igh Blood Cholesterol and A...
...rements of LDL-C and Non–HDL-...
1. In adults who are 20 years of age or old...
...who are 20 years of age or older and in who...
...ents with an LDL-C level less than 70 mg/dL...
...adults who are 20 years of age or older and...
Treatment
...eatmen...
...peutic Modalities...
...id-Lowering Drugs Among lipid-lower...
...-, Moderate-, and Low-Intensity Statin TherapyaH...
...nt Management Groups...
4.1. Secondary ASCVD Prevention
...In patients who are 75 years of age or younge...
...with clinical ASCVD in whom high-intensit...
...patients with clinical ASCVD who are...
...nts with clinical ASCVD who are judged to be...
...ients with clinical ASCVD who are on maxima...
... 6. At mid-2018 list prices, PCSK9...
...older than 75 years of age with clinic...
...patients older than 75 years of age who...
.... In patients with clinical ASCVD who are receivin...
...n patients with heart failure (HF) wi...
...linical atherosclerotic cardiovascular disease...
...igure 1. Secondary Prevention in Patie...
.... Very High-Riska of Future ASCVD EventsHaving tr...
...2. Severe Hypercholesterolemia (LDL-C ≥1...
...patients 20 to 75 years of age with an LDL-C le...
...ents 20 to 75 years of age with an...
...0 to 75 years of age with a baseline LD...
...30 to 75 years of age with heterozygous...
...0 to 75 years of age with a baseline LD...
...:6. Among patients with FH without evidence of cli...
.... Diabetes Mellitus in Adults...
.... In adults 40 to 75 years of age with...
...In adults 40 to 75 years of age with diabe...
...dults with diabetes mellitus who have...
...n adults older than 75 years of age with...
...In adults with diabetes mellitus and 10-year AS...
...er than 75 years with diabetes mellitus, it...
7. In adults 20 to 39 years of age with diabetes m...
...ble 3. Diabetes-Specific Risk Enhancers That...
...Primary Prevention...
...on and Risk AssessmentModerate intensity gener...
...Primary PreventionFigure 2. Primary...
...e 4. Risk-Enhancing Factors for Clinician–Pat...
...y Prevention Adults 40 to 75 Years of Age...
...dults at intermediate-risk, statin t...
...termediate-risk patients, LDL-C le...
...the primary prevention of clinical A...
...nd patients should engage in a risk discussion th...
...rmediate-risk adults, risk-enhancing...
...intermediate-risk or selected borderline-risk a...
...intermediate-risk adults or select...
...intermediate-risk adults who would benefit from...
9. In patients at borderline risk, in risk dis...
...clinical aASCVD includes acute coron...
...cklist for Clinician–Patient Share...
...e 6. Selected Examples of Candidates fo...
...toring in Response to LDL-C–Lowering Th...
...rence to changes in lifestyle and effects of LDL-...
...4.4. Primary Prevention in Other Age Groups...
...dults Additional recommendations for adults...
...5 years of age or older with an LDL...
...5 years of age or older, it may be reaso...
...76 to 80 years of age with an LDL-C l...
...hildren and Adolescents...
1. In children and adolescents with...
...n children and adolescents with lipid a...
...children and adolescents 10 years of age o...
...and adolescents with a family history of eithe...
...ldren and adolescents found to have moderate o...
...children and adolescents with obesity or oth...
...ren and adolescents without cardiovascula...
...ry of early aCVD is defined here as MI, docu...
...and Abnormal Lipid Values in Childhooda,b...
...er Populations at Risk...
...or clinical decision-making in adults of di...
.... Racial/Ethnic Issues in Evaluation,...
4.5.2. Hypertriglyceri...
...adults 20 years of age or older with moderat...
...to 75 years of age with moderate or severe hypertr...
...adults 40 to 75 years of age with severe...
...h severe hypertriglyceridemia (fasti...
...sues Specific to Women
...linicians should consider conditions specific to w...
2. Women of childbearing age who are...
...childbearing age with hypercholesterole...
....5.4 Adults Wit...
...ts 40 to 75 years of age with LDL-C 70 to 189 mg/d...
...ts with advanced kidney disease that...
...ts with advanced kidney disease who require dialys...
...5. Adults With Chronic Inflammatory Dis...
...0 to 75 years of age with LDL-C 70 to 189...
...ients with chronic inflammatory disorders...
...ults with RA who undergo ASCVD risk assessm...
...afety and Statin-Associated Side Effects...
...n-patient risk discussion is recommen...
...nts with statin-associated muscle symptoms (...
...In patients with indication for sta...
...s with statin-associated side effects that a...
...with increased diabetes mellitus risk or new-on...
...ients treated with statins, it is recommended...
...at increased ASCVD risk with chronic, stable li...
...patients at increased ASCVD risk with...
...yme Q10 is NOT recommended for routin...
...ts treated with statins, routine measurements of c...
...e 9. Statin-Associated Side Effects (S...
...mplementatio...
...ns focused on improving adherence to pres...
...linicians, health systems, and health plans sho...
...therapy is prescribed, a patient-clinician discu...
...st-Effectiveness Analysis for PCSK9 I...