11
Figure 1. Model of Steps in Lifestyle Therapies
Visit 1
a
• Begin lifestyle
therapies
Visit 2
• Evaluate
atherogenic
cholesterol
response
• If goal not
achieved,
intensify
atherogenic
cholesterol-
lowering
therapy
Visit 3
• Evaluate
atherogenic
cholesterol
response
• If goal not
achieved,
consider
adding drug
therapy
Visit N
b
• Monitor
adherence
to lifestyle
therapies
every 4-12
months
• Emphasize
reduction of
saturated fat and
cholesterol intakes
• Encourage
moderate physical
activity
• Encourage weight
loss, if overweight
or obese
• Recommend
referral to an
RDN
• Reinforce
recommendations
from Visit 1
• Consider adding
plant stanols/
sterols
• Increase viscous
fiber intake
• Recommend
referral to an
RDN
• Intensify weight
management and
physical activity
• Recommend
referral to an
RDN
a
For people at high or very high risk for ASCVD in whom drug therapy is indicated, it may be
started concomitantly with lifestyle therapies. For other patients, a trial of lifestyle therapies
should be undertaken before initiation of drug therapy.
b
In most cases, goal levels should be achieved in approximately 6 months.
Figure 2. Progression of Atherogenic-Cholesterol-Lowering
Drug Therapy
Initiate
atherogenic-
cholesterol-
lowering
drug therapy
(statin, unless
contraindicated
a
If goal not
achieved,
intensify
atherogenic-
cholesterol-
lowering drug
therapy
If goal not
achieved,
intensify drug
therapy or
refer to a lipid
specialist
Monitor
response and
adherence to
therapy every
4-12 months
b
a
A moderate or high-intensity statin should be first-line drug therapy for treatment of elevated
levels of atherogenic cholesterol, unless contraindicated. In a patient with very high triglycerides
(≥500 mg/dL), a triglyceride-lowering drug may be considered for first-line use to prevent
pancreatitis. Other ASCVD risk factors should be managed appropriately in parallel.
b
In most cases, goal levels should be achieved in approximately 6 months.
