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Table 1. Summary of Major Recommendations for the Treatment of Blood Cholesterol to Reduce ASCVD Risk in Adults Recommendations ACC/AHA COR ACC/AHA LOE A. Heart-healthy lifestyle habits should be encouraged for all individuals. B. e appropriate intensity of statin therapy should be initiated or continued: 1. Clinical ASCVD a a. Age ≤75 y and no safety concerns: High-intensity statin I A b. Age >75 y or safety concerns: Moderate-intensity statin I A 2. Primary prevention – Primary LDL-C ≥190 mg/dL a. Rule out secondary causes of hyperlipidemia (Table 3) I B b. Age ≥21y: High-intensity statin I B c. Achieve at least a 50% reduction in LDL-C IIa B d. LDL-C lowering nonstatin therapy may be considered to further reduce LDL-C IIb C 3. Primary prevention - Diabetes 40-75 years of age and LDL-C 70-189 mg/dL a. Moderate-intensity statin I A b. Consider high-intensity statin when ≥7.5% 10-y ASCVD risk using the Pooled Cohort Equations b IIa B 4. Primary prevention – No diabetes 40-75 years of age and LDL-C 70-189 mg/dL a. Estimate 10-y ASCVD risk using the Risk Calculator based on the Pooled Cohort Equations b in those NOT receiving a statin. Estimate risk every 4-6 y. I B b. To determine whether to initiate a statin, engage in a clinician-patient discussion of the potential for ASCVD risk reduction, adverse effects, drug–drug interactions, and patient preferences. Re-emphasize heart-healthy lifestyle habits and address other risk factors. IIa C i. ≥7.5% 10-y ASCVD risk: Moderate- or high-intensity statin I A ii. 5 to <7.5% 10-y ASCVD risk: Consider moderate-intensity statin IIa B iii. Other factors may be considered c : LDL-C ≥160 mg/dL, family history of premature ASCVD, hs-CRP ≥2.0 mg/L, CAC score ≥300 Agaston units, ABI <0.9 or lifetime ASCVD risk IIb C 5. Primary prevention when LDL-C <190 mg/dL and age <40 or >75 y, or <5% 10-y ASCVD risk IIb C a. Statin therapy may be considered in selected individuals when a risk decision is uncertain. c 6. e panel makes no recommendation for initiation of statin therapy for individuals with NYHA class II-IV heart failure or who are receiving maintenance hemodialysis. Treatment 2

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