Key Points
Î An elevated level of cholesterol carried by circulating apolipoprotein
(apo) B–containing lipoproteins (non-high-density lipoprotein
cholesterol [non-HDL-C] and low-density lipoprotein cholesterol
[LDL-C], termed atherogenic cholesterol) is a root cause of
atherosclerosis, the key underlying process contributing to most
clinical atherosclerotic cardiovascular disease (ASCVD) events.
Î Reducing elevated levels of atherogenic cholesterol will lower
ASCVD risk in proportion to the extent that atherogenic cholesterol
is reduced. This benefit is presumed to result from atherogenic
cholesterol lowering through multiple modalities, including lifestyle
modification and drug therapies.
Î The intensity of risk-reduction therapy should generally be adjusted to
the patient's absolute risk for an ASCVD event.
Î Atherosclerosis is a process that often begins early in life and
progresses for decades before resulting in a clinical ASCVD event.
Therefore, both intermediate-term and long-term/lifetime risk should
be considered when assessing the potential benefits and hazards of
risk-reduction therapies.
Î For patients in whom lipid-lowering drug therapy is indicated, statin
treatment is the primary modality for reducing ASCVD risk.
Î Non-lipid ASCVD risk factors should also be managed appropriately,
particularly high blood pressure, cigarette smoking, and diabetes mellitus.
Î In all adults (≥20 years of age), a fasting or nonfasting lipoprotein
profile should be obtained at least every 5 years.
• At a minimum, this should include total cholesterol (total-C) and HDL-C, which
allows calculation of non-HDL-C (total-C minus HDL-C). If fasting (generally
9-12 hours), the LDL-C level may be calculated, provided that the triglyceride
concentration is <400 mg/dL. (See Table 7)
• For those with atherogenic cholesterol levels in the desirable range, public health
recommendations regarding lifestyle should be emphasized.
2
Table 1. Criteria for Classification of ASCVD
• Myocardial infarction or other acute coronary syndrome
• Coronary or other revascularization procedure
• Transient ischemic attack
• Ischemic stroke
• Atherosclerotic peripheral arterial disease
▶ Includes ankle/brachial index <0.90
• Other documented atherosclerotic diseases such as:
▶ Coronary atherosclerosis
▶ Renal atherosclerosis
▶ Carotid plaque, ≥50% stenosis
▶ Aortic aneurysm secondary to atherosclerosis
