Primary preventive therapy in different patient subgroups
| Severe hypercholesterolemia |
| Initiate high-intensity statin therapy immediately, irrespective of 10-year risk of atherosclerotic cardiovascular disease (ASCVD) |
| Adding ezetimibe is reasonable if low-density lipoprotein cholesterol (LDL-C) is ≥ 190 mg/dL or there is less than 50% reduction in LDL-C levels with maximal tolerated statins |
| Consider adding a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor in patients with heterozygous familial hypercholesterolemia or with LDL-C ≥ 220 mg/dL with maximally tolerated statins and ezetimibe |
| Diabetes mellitus in adults |
| Irrespective of 10-year ASCVD risk, initiate moderate-intensity statin therapy immediately |
| Aim for reduction of LDL-C by at least 50% |
| Adults age 40–75 with LDL-C levels 70–189 mg/dL |
| Before starting statins, engage in clinician-patient risk discussion, evaluating risk factors, 10-year ASCVD risk, risk enhancers (Table 2), patient’s preference, costs, and adverse effects of statins |
| Use coronary artery calcium score to guide decision if risk is still unclear |
| Children and young adults |
| Assess risk factors in children age 0–19 years |
| Initiate statin therapy if patients have severely abnormal lipid profiles or clinical presentation of familial hypercholesterolemia and cannot be treated by 3 months lifestyle therapy |
| Ethnicity |
| Review racial and ethnic features that can influence ASCVD risk and intensity of treatment (Table 3) |
| Adults with chronic kidney disease |
| Starting moderate-intensity statin alone or in combination with ezetimibe can be useful |
| Adults with chronic inflammatory disorders and HIV |
| In adults age 40–75 with LDL-C 70–189 mg/dL with a 10-year ASCVD risk of over 5%, discuss moderate- or high-intensity statin therapy |
| Women |
| History of premature menopause (before age 40) or history of pregnancy-related disorders (hypertension, pre-eclampsia, gestational diabetes, small-for-gestational-age infants, and preterm deliveries) are risk-enhancing factors and should influence lifestyle and pharmacologic therapy decisions |
Based on information in references 1 and 2.