16
Diagnosis
Table 5. Checklist for Clinician–Patient Shared Decision-
Making for Initiating Therapy
Checklist Item
Recommendation Possible Management Strategy
Potential net clinical benefit
of pharmacotherapy
• Recommend statins as first-line therapy.
• Consider the combination of statin and nonstatin
therapy in selected patients.
• Discuss potential risk reduction from lipid-lowering
therapy.
• Discuss the potential for adverse effects or drug-drug
interactions.
Cost considerations • Discuss potential out-of-pocket cost of therapy to
the patient (e.g., insurance plan coverage, tier level,
copayment).
Shared decision-making • Encourage the patient to verbalize what was heard
(e.g., patient's personal ASCVD risk, available
options, and risks/benefits).
• Invite the patient to ask questions, express values and
preferences, and state ability to adhere to lifestyle
changes and medications.
• Refer patients to trustworthy materials to aid in their
understanding of issues regarding risk decisions.
• Collaborate with the patient to determine therapy
and follow-up plan.
a
ASCVD Risk Predictor Plus is available at: http://tools.acc.org/ASCVD-Risk-Estimator-Plus
Table 6. Selected Examples of Candidates for CAC
Measurement Who Might Benefit From Knowing
Their CAC Score Is Zero
• Patients reluctant to initiate statin therapy who wish to understand their risk and
potential for benefit more precisely
• Patients concerned about need to reinstitute statin therapy after discontinuation for
statin-associated symptoms
• Older patients (men, 55–80 y of age; women, 60–80 y of age) with low burden of risk
factors who question whether they would benefit from statin therapy
• Middle-aged adults (40-55 y of age) with PCE-calculated 10-year risk of ASCVD
5% to <7.5% with factors that increase their ASCVD risk, although they are in a
borderline risk group
Caveats: If patient is intermediate risk and if a risk decision is uncertain and a CAC
score is performed, it is reasonable to withhold statin therapy unless higher risk
conditions such as cigarette smoking, family history of premature ASCVD, or diabetes
mellitus are present, and to reassess CAC score in 5–10 years. Moreover, if CAC is
recommended, it should be performed in facilities that have current technolog y that
delivers the lowest radiation possible.
