Key Recommendations
- For patients with established ASCVD, high-intensity statins should be used to obtain ≥50% reduction in LDL. If this is not achieved, ezetimibe could be added and then a proprotein convertase subtilisin–kexin type 9 (PCSK9) inhibitor.
- For patients with very high risk (history of major ASCVD events, older age, diabetes, hypertension, smoking, familial hypercholesterolemia [FH], kidney disease, or heart failure) and LDL levels >70 mg/dL, adding ezetimibe is reasonable, followed by a PCSK9 inhibitor.
- For patients with severe hypercholesterolemia (LDL levels, >190 mg/dL), maximally tolerated statin therapy is recommended without risk calculations. If LDL is not reduced by 50%, clinicians can reasonably add ezetimibe.
- For patients with diabetes and LDL >70 mg/dL, a moderate-intensity statin is recommended; with elevated ASCVD risk, a high-intensity statin is reasonable.
- For primary prevention, adherence to a healthy lifestyle is the cornerstone of treatment across the lifespan. Clinician-patient discussions about risk assessment and treatment should consider “ASCVD risk enhancers,” such as family history, metabolic history, preeclampsia, inflammatory disease, ethnicity, and abnormal biomarkers.
- 10-year ASCVD risk scores between 7.5% and 19.9% are now considered “intermediate risk.” This broad category acknowledges uncertainty in risk-calculator estimates and is intended to encourage decision-making guided by patient preferences. For patients who elect drug treatment, a moderate-intensity statin is generally recommended.
- Coronary artery calcium (CAC) measurement is helpful when decisions about statin initiation are uncertain. Withholding or postponing statin initiation is reasonable if CAC=0 and the patient lacks other high-risk features. If CAC score is ≥100, statins should be initiated.
- To monitor adherence to therapy and reduction in LDL, clinicians should check lipids 1 to 3 months after a treatment change.
