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7 Table 4. Recommendations for Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults—Statin Treatment (continued) (High-, moderate-, and low-statin intensities are defined in Table 2) Recommendations Î 4. Before initiating statin therapy for the primary prevention of ASCVD in adults with LDL-C 70-189 mg/dL without clinical ASCVD a or diabetes, it is reasonable for clinicians and patients to engage in a discussion which considers the potential for ASCVD risk reduction benefits and for adverse effects, for drug–drug interactions, as well as patient preferences for treatment. (IIa-C) Î 5. In adults with LDL-C <190 mg/dL who are not otherwise identified in a statin benefit group, or for whom after quantitative risk assessment a risk-based treatment decision is uncertain, additional factors f may be considered to inform treatment decision making. In these individuals, statin therapy for primary prevention may be considered after evaluating the potential for ASCVD risk-reduction benefits, adverse effects, and drug–drug interactions and consider patient preferences. (IIb-C) Heart Failure and Hemodialysis Î 1. The Expert Panel makes no recommendations regarding the initiation or discontinuation of statins in patients with NYHA class II-IV ischemic systolic heart failure or in patients on maintenance hemodialysis. a Clinical ASCV D includes acute coronary syndromes, history of MI, stable or unstable angina, coronary or other arterial revascularization, stroke, TIA, or peripheral arterial disease presumed to be of atherosclerotic origin. b Contraindications, warnings, and precautions are defined for each statin according to the manufacturer's prescribing information. c Individuals with secondary causes of hyperlipidemia were excluded from RCTs reviewed. A triglyceride level ≥500 mg/dL was an exclusion criterion for almost all RCTs. erefore, ruling out secondary causes is necessary to avoid inappropriate statin therapy. d No RCTs included only individuals with LDL-C ≥190 mg/dL. However, many trials did include individuals with LDL-C ≥190 mg/dL and all of these trials consistently demonstrated a reduction in ASCV D events. In addition, the CTT meta-analyses have shown that each 39 mg/ dL reduction in LDL-C with statin therapy reduced ASCV D events by 22%, and the relative reductions in ASCV D events were consistent across the range of LDL-C levels. erefore, individuals with primary LDL-C ≥190 mg/dL should be treated with statin therapy. e Estimated 10-year or "hard" ASCV D risk includes first occurrence of nonfatal MI, CHD death, and nonfatal and fatal stroke as used by the Risk Assessment Work Group in developing the Pooled Cohort Equations. f ese factors may include primary LDL-C ≥160 mg/dL or other evidence of genetic hyperlipidemias; family history of premature ASCV D with onset <55 years in a first degree male relative or <65 years in a first degree female relative; high sensitivity-C-reactive protein ≥2 mg/L; CAC score ≥300 Agatston units or ≥75th percentile for age, sex, and ethnicity (for additional information, see http://www.mesa-nhlbi.org/CACReference.aspx.); ABI <0.9; or lifetime risk of ASCV D. Additional factors that may aid in individual risk assessment may be identified in the future.

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