Simplified lipid guidelines

Initiating screening: In patients without CVD (primary prevention), we suggest lipid testing as part of global CVD risk estimation in men at age ≥ 40 y and women at age ≥ 50 y (moderate-level evidence).

• -Testing can be considered earlier for patients with known traditional CVD risk factors including, but not limited to, hypertension, family history of premature CVD, diabetes, and smoking (low-level evidence).

Repeat screening: For patients not taking lipid-lowering therapy, we suggest lipid testing as part of global CVD risk estimation, performed no more than every 5 y (moderate-level evidence). Global CVD risk estimation can be repeated sooner if other CVD risk factors develop in the interim.

Patients do not need to fast for lipid testing. Nonfasting lipid levels can be used to calculate global CVD risk (moderate-level evidence).

Primary prevention: We encourage risk estimation with a CVD risk calculator (eg, Framingham) every time lipid testing is performed. Testing and risk estimation should be performed starting at age 40 y in men and 50 y in women (or earlier if indicated by other risk factors) until age 75 y (low-level evidence).

• -Primary prevention in patients with diabetes mellitus: We encourage risk estimation as above (low-level evidence).

• -Primary prevention in patients with CKD: We recommend using a CVD risk calculator (eg, QRISK2) that includes CKD in its estimation of risk (low-level evidence).

We discourage risk estimation for the following patients:

• -Those with pre-existing CVD, as they are automatically at high risk (high-level evidence).

• -Those < 40 y (without additional risk factors) and those > 75 y, as risk equations are not based on patients in these age ranges (low-level evidence).

• -Patients taking lipid therapy, as calculators are not designed to adjust for changes with lipid therapy (low-level evidence). If risk calculation is desired for patients taking lipid therapy, pretreatment lipid levels should be used and risk should be adjusted for known benefits of statin or ASA therapy.

We discourage the use of biomarkers as part of risk assessment until further evidence is available (moderate-level evidence).

Lifestyle interventions, including but not limited to smoking cessation, Mediterranean diet, and exercise, should be discussed with all patients (high-level evidence).

Secondary-prevention patients: We strongly encourage clinicians to discuss the risks and benefits of high-intensity statin therapy with patients (high-level evidence).

Primary-prevention patients: We suggest clinicians discuss the risks and benefits of moderate- or high-intensity statins with their patients based on an individual’s risk of CVD (high-level evidence).

• -For patients with a 10-y CVD risk of < 10%, we suggest retesting lipid levels in 5 y with risk estimation (moderate-level evidence).

• -For patients with a 10-y CVD risk of 10%–19%, we suggest clinicians discuss initiation of statins (preferably moderate-intensity statins) with patients (high-level evidence).

• -For patients with a 10-y CVD risk of ≥ 20%, we strongly encourage clinicians to discuss initiation of statins (preferably high-intensity) with patients (high-level evidence).

Patients who are elderly (based on frailty as much as age) or those with renal impairment can be offered lower-intensity statin therapy (low-level evidence).

Primary prevention patients > 75 y: We discourage routinely testing lipid levels, estimating CVD risk, and prescribing statins (moderate-level evidence).

• -Some patients > 75 y whose life expectancy and overall health status are good can be offered statin therapy for primary prevention, but this should be left to the clinician and patient’s discretion (low-level evidence).

Secondary prevention patients > 75 y: We strongly encourage clinicians to discuss the risks and benefits of moderate-intensity statins with patients (high-level evidence).

• -Patients already taking and tolerating a statin should not have their statin stopped or reduced just because they have aged beyond 75 y (low-level evidence).

In patients ≥ 65 y, pravastatin should likely not be considered first-line therapy until uncertainty surrounding cancer in this subgroup with this drug is resolved (moderate-level evidence).

Patients who do not tolerate a specific statin regimen should be offered a lower-intensity regimen, with either the same or a different statin, or a short drug holiday followed by rechallenge to help clarify if statins are related to the intolerance (low-level evidence).

• -Any statin intensity is preferred to non-statin lipid-lowering therapy (moderate-level evidence).

• -Alternate daily dosing can be considered if a patient does not tolerate daily dosing (low-level evidence).

• -In patients who have severe reactions like rhabdomyolysis, retrial might not be appropriate (low-level evidence).

In primary prevention, non-statin lipid-lowering drugs should not be used as first-line monotherapy or in combination with statins (high-level evidence).

In secondary prevention, ezetimibe can be considered in discussion with patients as add-on therapy to statins, but owing to the higher relative benefit of statins, statin therapy should be maximized first (to high intensity) (high-level evidence).

The use of cholesterol targets for reducing CVD is not required (high-level evidence).

We suggest that the monitoring of repeat lipid levels after a patient begins lipid-lowering therapy is not required (low-level evidence).

• -Adherence to statins can be improved with patient reinforcement.

We suggest that testing for baseline CK or ALT levels in healthy individuals before starting statin therapy is generally unnecessary (low-level evidence). The evidence against testing baseline ALT or CK levels is poor and some clinicians might prefer to test one or both.

Routine monitoring of CK and ALT levels should be reserved for those patients who are symptomatic or who are at higher risk of adverse events. Frequency should be determined at the discretion of the attending clinician (moderate-level evidence).

We discourage the use of ASA for patients without previous CVD and an estimated 10-y CVD risk < 20% (high-level evidence).

We suggest ASA can be considered in primary prevention if the 10-y CVD risk is ≥ 20% and bleeding risk is low (low-level evidence).

• -Use of ASA for primary CVD prevention should be considered after statin therapy has been discussed (high-level evidence).

Patients offered ASA should be informed of the potential benefits and harms of ASA use (low-level evidence).