9
Figure 1A. Recommendations for Statin Therapy for
ASCVD Prevention
Primary Prevention
(No diabetes, LDL-C 70 to 189 mg/dL, and not
receiving statin therapy)
Estimate 10-y ASCVD risk every 4-6 y
using Pooled Cohort Equations
b
DM age <40 or
>75 y or LDL-C
<70 mg/dL
<5% 10-y
ASCVD
risk
c
e
Potential ASCVD risk-reduction benefits. e absolute reduction in ASCVD events from
moderate- or high-intensity statin therapy can be approximated by multiplying the estimated
10-year ASCVD risk by the anticipated relative-risk reduction from the intensity of statin initiated
(~30% for moderate-intensity statin or ~45% for high-intensity statin therapy). e net ASCVD
risk-reduction benefit is estimated from the number of potential ASCVD events prevented with a
statin, compared to the number of potential excess adverse effects.
f
Potential adverse effects. e excess risk of diabetes is the main consideration in ~0.1 excess cases
per 100 individuals treated with a moderate-intensity statin for 1 year and ~0.3 excess cases per 100
individuals treated with a high-intensity statin for 1 year. In RCTs, both statin-treated and placebo-
treated participants experienced the same rate of muscle symptoms. e actual rate of statin-related
muscle symptoms in the clinical population is unclear. Muscle symptoms attributed to statin
therapy should be evaluated (see Table 4.)
Age <40 or >75 y
and LDL-C
<190 mg/dL
c
≥7.5% 10-y
ASCVD risk
(Moderate- or high-
intensity statin)
5% to <7.5% 10-y
ASCVD risk
(Moderate-
intensity statin)
In selected individuals,
additional factors may
be considered to inform
treatment decision making
d
Clinician-Patient Discussion
Prior to initiating statin therapy, discuss:
1. Potential for ASCVD risk-reduction benefits
e
2. Potential for adverse effects and drug–drug interactions
f
3. Heart-healthy lifestyle
4. Management of other risk factors
5. Patient preferences
6. If decision is unclear, consider primary LDL-C ≥160 mg/dL,
family histoy of premature ASCVD, lifetime ASCVD risk,
abnormal CAC scrore or ABI, or hs-CRP ≥2 mg/L
d
Emphasize adherence to lifestyle
Manage other risk factors
Monitor adherence
Encourage
adherence to
lifestyle
Initiate statin
at appropriate
intensity
Manage other
risk factors
Monitor
adherence
a
(See Figure 4)
NO to statin YES to statin
