4.1.1 Individuals at Low, Intermediate and High Risk:
Recommendation: We recommend management that does not include statin therapy for individuals at low risk (modified FRS < 10%) to decrease the risk of CVD events (Strong Recommendation; High-Quality Evidence).
Recommendation: We recommend management that includes statin therapy for individuals at intermediate risk (IR) (modified FRS 10%-19%) with LDL-C 3.5 mmol/L to decrease the risk of CVD events. Statin therapy should also be considered for IR persons with LDL-C < 3.5 mmol/L but with apoB 1.2 g/L or non-HDL-C 4.3 mmol/L or in men 50 years of age and older and women 60 years of age and older with 1 CV risk factor (Strong Recommendation; High-Quality Evidence).
Values and preferences: This recommendation applies to individuals with an LDL-C 1.8 mmol/L. Any decision regarding pharmacological therapy for CV risk reduction in IR persons needs to include a thorough discussion of risks, benefits, and cost of treatment, alternative nonpharmacological methods for CV risk reduction, and each individual’s preference. The proportional risk reduction associated with statin therapy in RCTs in (IR) persons is of magnitude similar to that attained in high-risk persons. Moreover, irreversible severe side effects are very rare and availability of generic statins results in a low cost of therapy. However, the absolute risk reduction is lower. Statin therapy might be considered in persons with FRS of 5%-9% with LDL-C 3.5 mmol/L or other CV risk factors because the proportional benefit from statin therapy will be similar in this group as well.
Recommendation: We recommend management that includes statin therapy for individuals at high risk (modified FRS 20%) to decrease the risk of CVD events (Strong Recommendation; High-Quality Evidence).
Individuals with Statin Indicated Conditions:
ABI, ankle-brachial index; ACR, albumin:creatinine ratio; eGFR, estimated glomerular ﬁltration rate; LDL-C, low-density lipoprotein cholesterol; TIA, transient ischemic attack.
Recommendation: We recommend management that includes statin therapy in high-risk conditions including clinical atherosclerosis, abdominal aortic aneurysm, most DM, CKD (age older than 50 years), and those with LDL-C 5.0 mmol/L to decrease the risk of CVD events and mortality (Strong Recommendation; High-Quality Evidence).
4.1.2 Treat to Target Approach
Recommendation: We recommend a treat-to-target approach in the management of dyslipidemia to mitigate CVD risk (Strong Recommendation; Moderate-Quality Evidence).
Recommendation: We recommend a target LDL-C consistently < 2.0 mmol/L or > 50% reduction of LDL-C in individuals for whom treatment is initiated to decrease the risk of CVD events and mortality (Strong Recommendation; Moderate- Quality Evidence).
Alternative target variables are apoB < 0.8 g/L or non- HDL-C < 2.6 mmol/L
(Strong Recommendation; Moderate-Quality Evidence).
Values and preferences: According to evidence from randomized trials in primary prevention, achieving these levels will reduce CVD events. The mortality reduction is statistically signiﬁcant but modest (NNT ¼ 250). Treatment in primary prevention values morbidity reduction preferentially.
Values and preferences: On the basis of the IMPROVE-IT trial, for those with a recent acute coronary syndrome and established coronary disease consideration should be given to more aggressive targets (LDL-C < 1.8 mmol/L or > 50% reduction). This might require the combination of ezetimibe (or other nonstatin medications) with maximally tolerated statin. This would value more aggressive treatment in higher-risk individuals.
Consider Initiating pharmaco-therapy if
High FRS (≥20%)
LDL-C < 2.0 mmol/L or > 50% ↓
Apo B < 0.8 g/L
non-HDL-C < 2.6 mmol/L
Intermediate FRS (10-19%)
LDL-C ≥ 3.5 mmol/L
or Non-HDL ≥ 4.3 mmol/L
or Apo B ≥ 1.2 g/L
or Men ≥ 50 and women ≥ 60 yrs and one additional CVD RF
Statin indicated conditions**
Abdominal aortic aneurysm
15 yrs duration for age >30 yrs (DM 1)
Chronic kidney disease (age ≥ 50 y)
eGFR < 60 mL/min/1.73 m2
or ACR > 3 mg/mmol
LDL-C ≥ 5. 0 mmol/L
>50% ↓ in LDL-C
FRS – modified Framingham Risk Score; ACR – albumin:creatinine ratio; * consider LDL-C < 1.8 mmol/L for subjects with ACS within last 3 months;** statins indicated as initial therapy