Table 3.

Practical application of evolving guidelines in primary prevention

RECOMMENDATION	DISCUSSION
Install a desktop calculator having characteristics congruent with your practice	CCS algorithms using FRS might be most appropriate for Canada^8,10 Quantification of dietary, exercise, and statin interventions are helpful Tool should include the following: real-time display of changes in risk factors and interventions that are turned on and off; graphics capability to display effects of risk factor changes on CVD risk; ability to generate cardiovascular age, which might improve patients’ understanding11,12; and decision support option for age thresholds, diabetes, and family history
Use 10-y CVD risk as threshold for treatment in place of LDL level	LDL levels are referenced only as extremes of the primary prevention spectrum and are no longer used as thresholds for intervention
Abandon treatment goals	In place of treatment goals ... maximize change in dietary pattern with patient input; maximize exercise interventions with patient input; optimize exercise and assess myalgia before statin introduction; use statin therapy according to degree of FRS; and consider dispensing with LDL follow-up unless you think it will motivate the patient. This concept might have to be introduced gradually
Use statin dosing according to level of FRS and patient tolerance	If intolerant, remember that a low-dose statin can give two-thirds of maximal lipid lowering¹³ High-risk patients require high-intensity dosing or maximally tolerated dosing Myalgia might respond to changes in dosing, timing, statin type, or dosing intensity¹⁴
Abandon hsCRP measurement as part of risk assessment	No longer part of treatment decision
Treat all patients with diabetes aged 40 to 75 y according to recommendations	Treat with moderate-intensity statin if no risk factors are present Treat with high-intensity statin if risk factors are present or the 10-y CVD risk is ≥ 7.5%
Treat all adults with LDL ≥ 5.0 mmol/L according to recommendations	Consider a secondary cause or familial hyperlipidemia Consider consultation
Make the patient part of the intervention decision	A lifestyle commitment can modify risk and reduce need for drug use¹⁵ Patients’ understanding of absolute risk reduction using statins might influence treatment threshold A 10-y CVD risk treatment threshold of 7.5% is always negotiable

CCS—Canadian Cardiovascular Society, CVD—cardiovascular disease, FRS—Framingham risk score, hsCRP—high-sensitivity C-reactive protein, LDL—low-density lipoprotein.