This document provides guidelines for the management of blood cholesterol to reduce atherosclerotic cardiovascular disease (ASCVD) risk. It outlines recommendations for primary and secondary prevention based on a patient's ASCVD risk factors, history, and LDL-C levels. For secondary prevention, maximal tolerated statin therapy is recommended. For primary prevention in diabetes patients, guidelines are provided based on age and 10-year ASCVD risk, with high-intensity statin therapy recommended for higher risk groups.
This document provides guidelines for the management of blood cholesterol to reduce atherosclerotic cardiovascular disease (ASCVD) risk. It outlines recommendations for primary and secondary prevention based on a patient's ASCVD risk factors, history, and LDL-C levels. For secondary prevention, maximal tolerated statin therapy is recommended. For primary prevention in diabetes patients, guidelines are provided based on age and 10-year ASCVD risk, with high-intensity statin therapy recommended for higher risk groups.
This document provides guidelines for the management of blood cholesterol to reduce atherosclerotic cardiovascular disease (ASCVD) risk. It outlines recommendations for primary and secondary prevention based on a patient's ASCVD risk factors, history, and LDL-C levels. For secondary prevention, maximal tolerated statin therapy is recommended. For primary prevention in diabetes patients, guidelines are provided based on age and 10-year ASCVD risk, with high-intensity statin therapy recommended for higher risk groups.
This document provides guidelines for the management of blood cholesterol to reduce atherosclerotic cardiovascular disease (ASCVD) risk. It outlines recommendations for primary and secondary prevention based on a patient's ASCVD risk factors, history, and LDL-C levels. For secondary prevention, maximal tolerated statin therapy is recommended. For primary prevention in diabetes patients, guidelines are provided based on age and 10-year ASCVD risk, with high-intensity statin therapy recommended for higher risk groups.
≥70 mg/dL: intensity ≥100 mg/dL: LDL-C LDL-C LDL-C Adding statin: Adding lowering lowering lowering ezetimibe is Aim for ezetimibe is 30–49% ≥50% 30–49% reasonable LDL-C reasonable lowering If multiple ≥50% ASCVD risk If LDL-C If LDL-C factors, ≥70 mg/dL ≥100 mg/dL: If 50-75 y or PCSK9-I moderate of age: non-HDL-C may be intensity High ≥100 mg/dL: considered statin: intensity Adding Aim for statin PCSK9-I is LDL-C reasonable lowering following 30–49% risk discussion
* Clinical ASCVD consists of acute coronary syndromes, those with history of myocardial infarction, stable or unstable angina or coronary other arterial revascularization, stroke, TIA, or peripheral artery disease including aortic aneurysm, all of atherosclerotic origin. † Major ASCVD events: Recent ACS, history of MI, history of Ischemic stroke, symptomatic PAD; High-Risk Conditions: ≥65 y of age, heterozygous FH, hx of HF, prior CABG or PCI, DM, HTN, CKD, current smoking, persistently elevated LDL-C≥100 mg/dL. ‡ Risk Enhancers: Family history of premature ASCVD, persistently elevated LDL-C ≥160 mg/dl, chronic kidney disease, metabolic syndrome, conditions specific to women (e.g. pre- eclampsia, premature menopause), inflammatory disease (especially psoriasis, RA, or HIV), ethnicity (e.g. South Asian ancestry), Lipid/biomarkers; persistently elevated triglycerides (≥175 mg/dL), if measured: hs-CRP ≥2.0 mg/L, Lp(a) levels ≥50 mg/dL or ≥125 nmol/l, apoB ≥130 mg/dL especially at higher levels of Lp(a), ABI <0.9. Ch Secondary prevention ( age 18Y +)
Clinical ASCVD (All vascular conditions of
atherosclerotic origin): Acute coronary syndromes (ACS), History of myocardial infarction (MI), Stable or unstable angina, Coronary artery revascularization, Brain stroke, Transient ischemic attack (TIA), Peripheral artery disease including aortic aneurysm, Ischemic HFrEF Ch
*In patients with diabetes mellitus at higher risk, especially those with multiple risk factors or those 50 to 75 years of age or 10- year risk is 7.5% or higher, it is reasonable to use a high-intensity statin to reduce the LDL-C level by ≥50%. *In adults with diabetes mellitus and a 10-year ASCVD risk of 20% or higher, adding ezetimibe to maximally tolerated statin therapy may be considered to reduce low-density lipoprotein cholesterol (LDL-C) levels by 50% or more.
Diabetes Mellitus 20- 39y 40-75 y
Diabetes-specific risk enhancers Risk assessment Pooled cohort -Long duration (≥10 y DM2, 20 y DM1 < 7.5% 7.5-20 % >20% -Albuminuria High intensity Moderate High intensity (≥30 mcg of albumin/mg CR statin statin +ezetimibe -Glomerular filtration rate Intensity (eGFR) less than 60 mL/min/1.73 m2 -Retinopathy, neuropathy, or - ABI (<0.9),
If present, it is reasonable to initiate statin Ch
Non-modifiable: 1. Age (M ≥ 45 & F ≥ 55) st 2. Premature CVD in 1 degree relatives (M < 55 & F < 65) 3. CKD stage 3 & 4 (relatively fixed risk factor) Modifiable: 4. High LDL-C 5. Low HDL (< 40) 6. HTN, BP ≥ 140/90 7. Diabetes/metabolic syndrome 8. Cigarette smoking
Additional risk factors
9. Coronary artery calcification
10. PCOS 11. CRP Ch
1 2 3 4
Stable ASCVD without other ≥ 50% reduction, or LDL < 100 ≥ 50% reduction, or LDL < 100 30-49% reduction, or LDL < 100 comorbidities on statin for on max dose or non-HDL< 130 on moderate intensity statin 2ry prevention
With ASCVD plus other ≥ 50% reduction
comorbidities Goal? [or LDL< 70 or non (DM, ASCVD < 3 months, HDL < 100 on max poor control on statin, High dose] Lp(a), CKD) NO
With ASCVD and baseline
LDL ≥ 190, on statin for 2ry Goal? prevention #
NO
BAS if TG < 300
Preferred in cohorts 1,2 & add-on to statin in HeFH
# only in LDL-C > 190
N.B. PCSK-9 Inhibitor, Mipomersan, Lomitapide are not indicated in
