RISK CATEGORY | AHA-ACC1 | CCS2 | RATIONALE | IMPLEMENTATION |
---|---|---|---|---|
LDL level used as threshold or target for treatment |
|
| Statin trials have been randomized to dose or potency, but never to thresholds or targets |
|
Basis of 10-y global risk assessment | Pooled cohort equations |
| 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% |
| Pooled cohort equations are well validated in the United States, and intervention is effective down to risk levels as low as 5% |
|
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 |
| 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 |
| 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.