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
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
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.