15
4.4.2. Primary Prevention Adults 40 to 75 Years of Age With
LDL-C Levels 70 to 189 mg/dL (1.7 to 4.8 mmol/L)
COR LOE
Recommendations
IIb B-R 8. In intermediate-risk adults who would benefit from more
aggressive LDL-C lowering and in whom high-intensity
statins are advisable but not acceptable or tolerated, it may
be reasonable to add a nonstatin drug (ezetimibe or bile acid
sequestrant) to a moderate-intensity statin.
IIb B-R 9. In patients at borderline risk, in risk discussion, the presence
of risk-enhancing factors may justify initiation of moderate-
intensity statin therapy.
a
Definition of clinical ASCVD includes acute coronary syndrome (ACS), those with history
of myocardial infarction (MI), stable or unstable angina or coronary or other arterial
revascularization, stroke, transient ischemic attack (TIA), or peripheral artery disease (PAD)
including aortic aneurysm, all of atherosclerotic origin.
Table 5. Checklist for Clinician–Patient Shared Decision-
Making for Initiating Therapy
Checklist Item
Recommendation Possible Management Strategy
ASCVD risk assessment • Assign to statin treatment group; use ASCVD Risk
Estimator Plus.
a
▶ In lower-risk primary-prevention adults 40-75 y
of age with LDL-C ≥70 mg/dL (≥1.8 mmol/L).
▶ Not needed in secondary prevention, in those
with LDL-C ≥190 mg/dL (≥4.9 mmol/L), or in
those 40-75 y of age with diabetes mellitus.
• Assess other patient characteristics that influence
risk. See Risk-Enhancing Factors (see Table 4)
• Assess CAC if risk decision is uncertain and
additional information is needed to clarify ASCVD
risk.
▶ Use decision tools to explain risk (e.g., ASCVD
Risk Estimator Plus,* Mayo Clinic Statin Choice
Decision Aid).
Lifestyle modifications • Review lifestyle habits (e.g., diet, physical activity,
weight or body mass index, and tobacco use).
• Endorse a healthy lifestyle and provide relevant
advice, materials, or referrals. (e.g., CardioSmart,
AHA Life's Simple 7, NLA Patient Tear Sheets,
PCNA Clinicians' Lifestyle Modification Toolbox,
cardiac rehabilitation, dietitian, smoking cessation
program).
