— Treating to LDL cholesterol targets is no longer recommended;
rather, clinicians should determine whether a patient falls into one
of four mutually exclusive high-risk groups and should initiate statin
therapy as follows:
Patients with clinical atherosclerotic cardiovascular disease (ASCVD)
should receive high-intensity (age, <75) or moderate-intensity (age,
≥75) statin therapy.
Patients with LDL cholesterol levels ≥190 mg/dL should receive high-
intensity statin therapy.
Diabetic patients aged 40–75 with LDL cholesterol levels of 70–189
mg/dL and without clinical ASCVD should receive at least moderate-
intensity statin therapy (and possibly high-intensity statin therapy
when estimated 10-year ASCVD risk is ≥7.5%).
Patients without clinical ASCVD or diabetes but with LDL cholesterol
levels of 70–189 mg/dL and estimated 10-year ASCVD risk ≥7.5%
should receive moderate- or high-intensity statin therapy.
— High-intensity statin therapies are atorvastatin (40–80 mg) or
rosuvastatin (Crestor; 20–40 mg). Moderate-intensity statin therapies
include atorvastatin (10–20 mg), rosuvastatin (5–10 mg),
simvastatin (20–40 mg), pravastatin (40–80 mg), and several others.
— With few exceptions, use of lipid-modifying drugs other than
statins is discouraged.
— Ten-year ASCVD risk — which includes both coronary events and
stroke — is determined using an online calculator that can be
accessed through the AHA and ACC websites. For further discussion of
the new risk-assessment tool, see NEJM JW Gen Med Nov 12 2013.
— Lifestyle modification is recommended for all patients, regardless
of cholesterol-lowering drug therapy.