Sponsoring organization: American College of Cardiology/American Heart Association (ACC/AHA)
Target Population: Primary care providers, cardiologists
Background and Objective
To guide clinicians in treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults.
— Treating to LDL cholesterol targets is no longer recommended; rather, clinicians should determine whether a patient falls into one of four mutually exclusive high-risk groups and should initiate statin therapy as follows:
Patients with clinical atherosclerotic cardiovascular disease (ASCVD) should receive high-intensity (age, <75) or moderate-intensity (age, ≥75) statin therapy.
Patients with LDL cholesterol levels ≥190 mg/dL should receive high-intensity statin therapy.
Diabetic patients aged 40–75 with LDL cholesterol levels of 70–189 mg/dL and without clinical ASCVD should receive at least moderate-intensity statin therapy (and possibly high-intensity statin therapy when estimated 10-year ASCVD risk is ≥7.5%).
Patients without clinical ASCVD or diabetes but with LDL cholesterol levels of 70–189 mg/dL and estimated 10-year ASCVD risk ≥7.5% should receive moderate- or high-intensity statin therapy.
— High-intensity statin therapies are atorvastatin (40–80 mg) or rosuvastatin (Crestor; 20–40 mg). Moderate-intensity statin therapies include atorvastatin (10–20 mg), rosuvastatin (5–10 mg), simvastatin (20–40 mg), pravastatin (40–80 mg), and several others.
— With few exceptions, use of lipid-modifying drugs other than statins is discouraged.
— Ten-year ASCVD risk — which includes both coronary events and stroke — is determined using an online calculator that can be accessed through the AHA and ACC websites. For further discussion of the new risk-assessment tool, see NEJM JW Gen Med Nov 12 2013.
— Lifestyle modification is recommended for all patients, regardless of cholesterol-lowering drug therapy.
This guideline is designed explicitly to replace the widely used ATP3 guideline from the National Heart, Lung, and Blood Institutes, last updated in 2004. The obvious major change is that clinicians now are directed to initiate either moderate-intensity or high-intensity statin therapy for patients who fall into the four aforementioned categories, without titration to a specific LDL cholesterol target. Measuring lipids during follow-up of drug-treated patients is done to assess adherence to treatment and not to see whether a specific LDL cholesterol target has been achieved.
Editor Disclosures at Time of Publication