Table 1.

The AHA-ACC statin guidelines compared with the CCS guidelines

RISK CATEGORY	AHA-ACC¹	CCS²	RATIONALE	IMPLEMENTATION
LDL level used as threshold or target for treatment	No treatment if LDL < 2.0 mmol/L Look for FH or secondary cause if LDL > 5.0 mmol/L LDL level not otherwise a target or threshold	Treatment threshold of LDL > 3.5 mmol/L if intermediate risk Treatment if LDL > 5.0 mmol/L Treatment target LDL ≤ 2.0 mmol/L or reduced to ≤ 50%	Statin trials have been randomized to dose or potency, but never to thresholds or targets	LDL is rarely a trigger for treatment and does not need to be followed as an end point for treatment No LDL goals for therapy
Basis of 10-y global risk assessment	Pooled cohort equations	FRS Validated in Canada⁸	Appropriate weighting of risk for the black population	Pooled cohort equations used in place of FRS to calculate 10-y risk
10-y global CVD risk used as threshold for treatment	For those aged 40 to 75 y with no cardiovascular or metabolic disease, treatment threshold derived from pooled cohort equation is ≥ 7.5%	FRS used to determine risk as low (< 10%), intermediate (≥ 10% to < 20%), or high (≥ 20%) FRS ≥ 20% always treated	Pooled cohort equations are well validated in the United States, and intervention is effective down to risk levels as low as 5%	Risk ≥ 7.5% used as threshold for intervention for those aged 40 to 75 y as primary prevention Decision needed for high- or low-dose statin
Use of hsCRP levels to further refine treatment threshold	Not used	Treatment suggested if intermediate risk, LDL < 3.5 mmol/L, and hsCRP ≥ 2 mg/L in certain age groups	No trials exist using the hsCRP variable as an independent risk modifier or in a dosing study No better than FRS on meta-analysis9	Not part of risk assessment
Established CVD (secondary prevention)	All treated	All treated	Maximum intervention used in established disease	All patients with established CVD treated with high-intensity statins
LDL levels > 5.0 mmol/L	Treatment recommended; look for FH or secondary cause of high lipid levels	Treatment recommended; look for FH or secondary cause of high lipid levels	Alternate treatment might help if a secondary cause is found High lipid levels owing to FH might require consultation	Consider high-dose statins in this group
Diabetes	Those with type 2 diabetes aged 40 to 75 y with risk factors present or with 10-y risk ≥ 7.5% should receive high-intensity statin therapy; they should receive moderate-dose statins if no risk factors are present	Patients with diabetes aged > 40 y, or with > 15-y duration of diabetes, or with microvascular disease should be treated as high risk	Patients with diabetes evaluated by 10-y risk as usual, but become high-risk equivalent if risk factors are present	Treat those aged 40 to 75 y with high-dose statins if risk factors are present; treat with moderate-dose statins if no risk factors are present
Chronic kidney disease	Treat according to 10-y risk status with exception of dialysis patients	Treat as high-risk equivalent with exception of dialysis patients	Not addressed as a separate group	Treat according to 10-y risk unless undergoing dialysis
Non-HDL or Apo B levels as alternate targets	No recommendation	Specific goals for non-HDL cholesterol and Apo B levels	No randomized trials exist to show benefit for lipid level or particle number goals	No lipid level or particle number goals for therapy
Alternative drugs to statins	None	Drugs added to achieve target LDL levels	No evidence for benefit of other drugs added to statins	Statins are the only recommended lipid-lowering agents

ACC—American College of Cardiology, AHA—American Heart Association, Apo B—apolipoprotein B, CCS—Canadian Cardiovascular Society, CVD—cardiovascular disease, FH—familial hypercholesterolemia, FRS—Framingham risk score, HDL—high-density lipoprotein, hsCRP—high-sensitivity C-reactive protein, LDL—low-density lipoprotein.