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Risk Assessment 4 Table 4. Criteria for ASCVD Risk Assessment, Treatment Goals for Atherogenic Cholesterol, and Levels at Which to Consider Drug Therapy (mg/dL) Risk Category Criteria Treatment Goal Consider Drug erapy Non-HDL-C mg/dL LDL-C mg/dL Non-HDL-C mg/dL LDL-C mg/dL Low • 0-1 major ASCVD risk factors • Consider other risk indicators, if known <130 <100 ≥190 ≥160 Moderate • 2 major ASCVD risk factors • Consider quantitative risk scoring • Consider other risk indicators a <130 <100 ≥160 ≥130 High • ≥3 major ASCVD risk factors • Diabetes mellitus (type 1 or 2) b ▶ 0-1 other major ASCVD risk factors, and ▶ No evidence of end organ damage • Chronic kidney disease stage 3B or 4 c • LDL-C ≥190 mg/dL (severe hypercholesterolemia) d • Quantitative risk score reaching the high-risk threshold e <130 <100 ≥130 ≥100 Very High • ASCVD • Diabetes mellitus (type 1 or 2) ▶ ≥2 other major ASCVD risk factors, or ▶ Evidence of end organ damage f <100 <70 ≥100 ≥70 For patients with ASCVD or diabetes mellitus, consideration should be given to use of moderate or high-intensity statin therapy, irrespective of baseline atherogenic cholesterol levels. a For those at moderate risk, additional testing may be considered for some patients to assist with decisions about risk stratification. (See Tables 9 and 11 and text for additional details) b For patients with diabetes plus 1 major ASCVD risk factor, treating to a non-HDL-C goal of <100 mg/ dL (LDL-C <70 mg/dL) is considered a therapeutic option. c For patients with chronic kidney disease (CKD) stage 3B (glomerular filtration rate [GFR] 30-44 mL/ min/1.73 m 2 ) or stage 4 (GFR 15-29 mL/min/1.73 m 2 ) risk calculators should not be used because they may underestimate risk. Stage 5 CKD (or on hemodialysis) is a very high risk condition, but results from randomized, controlled trials of lipid-altering therapies have not provided convincing evidence of reduced ASCVD events in such patients. erefore, no treatment goals for lipid therapy have been defined for stage 5 CKD. d If LDL-C is ≥190 mg/dL, consider severe hypercholesterolemia phenotype, which includes familial hypercholesterolemia (FH). Lifestyle intervention and pharmacotherapy are recommended for adults with the severe hypercholesterolemia phenotype. If it is not possible to attain desirable levels of atherogenic cholesterol, a reduction of at least 50% is recommended. For FH patients with multiple or poorly controlled other major ASCVD risk factors, clinicians may consider targeting even lower levels of atherogenic cholesterol. Risk calculators should not be used in such patients. e High-risk threshold is defined as ≥10% using Adult Treatment Panel (ATP) III Framingham Risk Score for hard CHD (MI or CHD death), ≥15% using the 2013 Pooled Cohort Equations for hard ASCVD (MI, stroke or death from CHD or stroke), or ≥45% using the Framingham long-term (to age 80) cardiovascular disease (MI, CHD death or stroke) risk calculation. Clinicians may prefer to use other risk calculators but should be aware that quantitative risk calculators vary in the clinical outcomes predicted (eg, CHD events, ASCVD events, cardiovascular mortality), the risk factors included in their calculation, and the time frame for their prediction (eg, 5 years, 10 years, or long-term or lifetime). Such calculators may omit certain risk indicators that can be very important in individual patients, provide only an approximate risk estimate, and require clinical judgment for interpretation. f End organ damage indicated by increased albumin/creatinine ratio (≥30 mg/g ), CKD, or retinopathy.