Table 3.

Practical application of evolving guidelines in primary prevention

Install a desktop calculator having characteristics congruent with your practiceCCS algorithms using FRS might be most appropriate for Canada8,10
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 levelLDL levels are referenced only as extremes of the primary prevention spectrum and are no longer used as thresholds for intervention
Abandon treatment goalsIn 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 toleranceIf 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 assessmentNo longer part of treatment decision
Treat all patients with diabetes aged 40 to 75 y according to recommendationsTreat 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 recommendationsConsider a secondary cause or familial hyperlipidemia
Consider consultation
Make the patient part of the intervention decisionA 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.