The USPSTF has issued a grade A recommendation for routine lipid screening for all men of age >35 years and women >45 years who are at increased risk for CHD.75 The Task Force also issued a grade B recommendation to screen for lipid disorders beginning at age 20 years for men and women who have diabetes, hypertension, obesity, tobacco use, noncoronary atherosclerosis, or family history of early CVD. These recommendations are currently being updated.
In 2014, the ACC/AHA published "a guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults." This guideline offers evidence-based recommendations on using statins to treat cholesterol in high-risk groups (Fig. 1). Persons with clinical atherosclerotic CVD include "those with an acute coronary syndrome and those with a history of MI, stable or unstable, angina, coronary of other arterial revascularization, or stroke, transient ischemic attack, or peripheral arterial disease … of atherosclerotic origin." In addition, the ACC/AHA provides a calculator for clinicians and patients to estimate 10-year and lifetime gender and race-specific risks for CHD and stroke events to guide statin use for primary prevention: ACC/AHA Risk Calculator.
FIGURE 1. American College of Cardiology/American Heart Association cholesterol guideline, 2013.
Use the CVD risk calculators to establish 10-year risk. The most recent ACC/AHA Cholesterol Guideline provides evidence-based recommendations for initiating statin therapy based on risk level. The recommendations shown in Figure 1. are briefly summarized below. The guideline notes that high-intensity therapy lowers LDL by about 50% and moderate-intensity therapy lowers LDL by 30% to 50%.
■ For patients with clinical CVD (secondary prevention) or LDL cholesterol levels >190 mg/dL (primary prevention)—prescribe high-intensity statin therapy.
■ For patients with diabetes and/or LDL cholesterol levels from 70 to 189 mg/dL—determine the 10-year risk of atherosclerotic CVD with the new risk calculator (see above). Although the evidence for initiating statins for primary prevention is stronger for adults with 10-year risks above 7.5%, statins can also be considered for risk levels between 5% and<7.5%.
■ However, the guideline also states that clinicians and patients should engage in shared decision making, addressing the potential benefits and harms of prescribing statins and eliciting patient preferences before initiating therapy. The guideline firmly emphasizes the importance of encouraging all patients to adhere to a healthy lifestyle.
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