Dyslipidemia management in primary prevention of cardiovascular disease: Current guidelines and strategies

Table 1 Fixed-dose strategies

Strategy	ACC/AHA 2013	NICE 2014	VA/DoD 2014
Risk score	PCE to determine 10-yr risk of non-fatal and fatal hard ASCVD events (CHD and CVA)	QRISK2 to determine 10-yr risk of non-fatal and fatal CVD events (CHD, CVA, PAD)	FRS or PCE to determine 10-yr risk of non-fatal and fatal CVD events
Step 1: Identify statin-benefit group	Statin benefit groups: (moderate to high-intensity statin) History of ASCVD; LDL-C ≥ 190, age ≥ 21; DM at age 40-75 with LDL-C ≥ 70; ≥ 7.5% of ASCVD risk at age 40-75 with LDL-C; ≥ 70 (in some individuals, not all; discussion required) Consider moderate intensity statin as initial dose for: DM with ≤ 7.5% ASCVD risk; ≥ 7.5% of ASCVD risk without DM Inadequate data to make recommendation (weigh risk, benefit and patient preference) DM at age < 40 or > 75 with LDL-C > 70; Age < 40 or > 75 with LDL-C > 70; 5%-7.4% of ASCVD risk at age 40-75 with LDL-C > 70; < 5% of ASCVD risk at age 40-75 with LDL-C > 70; Age < 40 with low 10 yr ASCVD risk but high lifetime risk based on 1 strong or multiple risk factors; Those with serious co-morbidities and increased ASCVD risk (e.g., HIV, rheumatologic or inflammatory diseases, or solid organ transplantation) Other factors for consideration: family history of premature CVD, hsCRP ≥ 2, elevated CAC, ABI < 0.9, LDL-C ≥ 160	Statin benefit groups: (initial dose: Atorvastatin 20 mg/d) Type 1 DM; CKD st. III; Risk score > 10%; Age > 85; Familial hypercholesterolemia Elevated risk groups that are underestimated by or not included in QRISK2: Possible benefit with statin HIV; Serious mental problem; On medication that cause dyslipidemia (antipsychotic, corticosteroid, immunosuppressant); Autoimmune disorder and systemic inflammatory disorder; TG > 175; On anti-hypertension or lipid modification therapy; Recently stopped smoking	Statin benefit group: (initial dose: Atorvastatin 10-20 mg/d) Risk score > 12% Moderate dose statin initiation can be considered in patient with 6%-12% risk score after discussion of benefit, risk, and patients’ preference
Step 2: Determine adequacy of treatment effect	For group treated with high intensity statin: > 50% ↓ of LDL-C For group treated with moderate intensity statin: 30%-50% ↓ of LDL-C If patients are already on statin and baseline LDL-C is unknown, an LDL-C < 100 was observed in most individuals receiving high-intensity statin therapy in RCTs	> 40% ↓ of non-HDL-C	No objective parameters recommended
Step 3: Follow-up lipids	1-3 mo after initiation therapy Every 3-12 mo as clinically indicated thereafter	3 mo after initiation of therapy Annually when target achieved	Not recommended Lipid measurement can be utilized for compliance monitoring
Step 4: Options if treatment effect judged not adequate	Reinforce lifestyle change and adherence to medication Exclude secondary cause of dyslipidemia Add non-statin agent in those with LDL-C ≥ 190 or DM at age 40-75 with LDL-C ≥ 70	Discuss adherence to lifestyle and medication Up-titrate statin dose; may go up to a torvastatin 80 mg/d	No recommendation

ACC/AHA: American College of Cardiology/American Heart Association; NICE: National Institute for Health and Care Excellence; PCE: Pooled Cohort Equations; ASCVD: Atherosclerotic cardiovascular disease; CHD: Coronary heart disease; CVA: Cerebrovascular accident; CVD: Cardiovascular disease; PAD: Peripheral artery disease; FRS: Framingham Risk Score; LDL-C: Low density lipoprotein cholesterol; HDL-C: High density lipoprotein cholesterol; DM: Diabetes mellitus; CKD: Chronic kidney disease; HIV: Human immunodeficiency virus; TG: Triglyceride; hsCRP: High sensitivity C-reactive protein; ABI: Ankle-brachial index; RCT: Randomized controlled trials.