T1 15.3 %  Initial Visit or Follow Up Visit
Current 10-Year
ASCVD Risk
~%
Previous 10-Year
ASCVD Risk
~%

Lifetime ASCVD Risk    Lifetime Risk Calculator only provides lifetime risk estimates for individuals 40 to 59 years of age.

Estimate Risk
Must enter ALL parameters to derive the ASCVD Risk

Welcome to the ASCVD Risk Estimator Plus
For optimal use:
  • Estimate patient’s 10-year ASCVD risk at an initial visit to establish a reference point
  • Forecast the potential impact of different interventions on patient risk.
  • Reassess ASCVD risk at follow-up visits. Follow up risk incorporates change in risk factor levels over time and requires both initial and follow up values.
  • Use the information above to help with clinician-patient discussions on risk and risk-lowering interventions.

See the “About” screen in this app for a definition of terms and additional instructions.

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App intended for primary prevention patients without ASCVD and LDL-C < 190 mg/dL (4.921 mmol/L)

Patient Demographics

Age must be between 40-79
Note: These estimates may underestimate the 10-year and lifetime risk for persons from some race/ethnic groups, especially American Indians, some Asian Americans (e.g., of south Asian ancestry), and some Hispanics (e.g., Puerto Ricans), and may overestimate the risk for others, including some Asian Americans (e.g., of east Asian ancestry) and some Hispanics (e.g., Mexican Americans). Because the primary use of these risk estimates is to facilitate the very important discussion regarding risk reduction through lifestyle change, the imprecision introduced is small enough to justify proceeding with lifestyle change counseling informed by these results.

Current Labs/Exam

Value must be between 130 - 320
Value must be between 3.367 - 8.288
Value must be between 20 - 100
Value must be between 0.518 - 2.59
Value must be between 30-300
Value must be between 0.777-7.770
Value must be between 90-200

Personal History

Do you want to compare to risk level at a previous visit?

Tip: This will also allow the app to more precisely calculate a patient’s current risk by accounting for changes in their risk factor levels over time.

Values at Previous Visit

Age is Missing
Age must be between 40-79
Total Cholesterol is Missing
Value must be between 130 - 320
Value must be between 3.367 - 8.288
Value must be between 20 - 100
Value must be between 0.518 - 2.59
LDL Cholesterol at Initial Visit is Missing
Value must be between 30-300
Value must be between 0.777-7.770
Systolic Blood Pressure is Missing
Value must be between 90-200
Treatment Hypertension is Missing
Therapy Impact  
Potential risk reduction impact of different therapies can only be calculated for patients at an initial visit.
Therapy Impact  
Potential risk reduction impact of different therapies can only be calculated for patients at an initial visit.

Risk Reduction by Therapy

Therapy(s) Projected ASCVD Risk for this patient if Therapy Initiated
Statin*
BP drug(s)**
Stop smoking†
Aspirinǂ
Statin + Aspirin
BP drug(s) + Aspirin
Statin + BP drug(s)
Statin + Stop smoking
Stop smoking + Aspirin
BP drug(s) + Stop smoking
Statin + BP drug(s) + Aspirin
BP drug(s) + Stop smoking + Aspirin
Statin + BP drug(s) + Stop smoking
Statin + Stop smoking + Aspirin
Statin + BP drug(s) + Stop smoking + Aspirin
*Start moderate intensity statin, or intensify statin from a moderate to a high intensity dose.
**Start blood-pressure lowering medication if not currently taking, or add BP-lowering med (s) to patient’s existing regime.
†Stop smoking for two years
ǂStart or continue taking aspirin.
¶ NA = Not Applicable. Risk is not shown for therapy(s) that are not recommended. Guidelines do not recommend statin therapy for patients with 10-year ASCVD risk <5%. Guidelines do not typically recommend aspirin therapy for patients with 10-year risk <10%. It is assumed there is no additional BP-lowering benefit with medication for patient with SBP <120 mmHg (<130 mmHg w/diabetes).

Review Therapy Advice for this Patient

Continue usual care at MD’s discretion.

  • BP:
  • LDL-C:
  • Aspirin:
  • Smoking:

Lifestyle:This tool is meant to help decision making around use of statin, blood pressure medication, aspirin, and smoking cessation to lower risk, based on a particular evidence base.However, AHA/ACC guidelines stress the importance of lifestyle modification as the foundation to lowering cardiovascular disease risk, and decisions around these therapies are assumed to be in the context of guideline-recommended lifestyle interventions



Project Risk Reduction by Therapy

Projected 10-Year ASCVD Risk

T1 15.3 %  Stop Smoking, Add Statin Treatments

  Add New Treatment Scenario


*Guidelines do not recommend statin therapy for patients with 10-year risk < 5%
*Guidelines do not typically recommend aspirin therapy for patients with 10-year risk < 10%
*Assumed there is no additional BP-lowering benefit with medication for patient with SBP <120 mmHg (<130 mmHg w/ diabetes)
Projected 10-Year ASCVD Risk

T2 15.3 %  Stop Smoking, Add Statin Treatments

  Project a Different Therapy Combination


*Guidelines do not recommend statin therapy for patients with 10-year risk < 5%
*Guidelines do not typically recommend aspirin therapy for patients with 10-year risk < 10%
*Assumed there is no additional BP-lowering benefit with medication for patient with SBP <120 mmHg (<130 mmHg w/ diabetes)
Projected 10-Year ASCVD Risk

T3 15.3 %  Stop Smoking, Add Statin Treatments

  Project a Different Therapy Combination


*Guidelines do not recommend statin therapy for patients with 10-year risk < 5%
*Guidelines do not typically recommend aspirin therapy for patients with 10-year risk < 10%
*Assumed there is no additional BP-lowering benefit with medication for patient with SBP <120 mmHg (<130 mmHg w/ diabetes)

Visit Summary Below is a summary of patient’s risk, treatment options, and treatment advice based on the data provided

Email Advice
Estimated 10-Year ASCVD Risk Profile

  • Actual Risk
  • Projected Risk

Enter potential treatment scenarios on the "Therapy Impact" tab to plot them on the graph above as well.


*Projected Risk with the following therapies:
  • A = Start or continue taking aspirin
  • B = Start, add, or intensify blood pressure medication
  • C = Manage cholesterol by starting or intensifying statin
  • S = Stop smoking for at least 2 years

Treatment Advice Summary

ACC Lifestyle Recommendations

Therapy Safety Information


Inputs

  • Sex: Female
  • Race: White
  • Values Previous Current Current (Follow-Up)
    Age:
    Total Cholesterol (mg/dL) (mmol/L) 240
    HDL Cholesterol (mg/dL) (mmol/L)
    LDL Cholesterol (mg/dL) (mmol/L)
    Systolic Blood Pressure(mm Hg) 98 140
    Diabetes:
    Smoker:
    Treatment for Hypertension: Yes
    Aspirin Therapy:
    Statin:
Note: These estimates may underestimate the 10-year and lifetime risk for persons from some race/ethnic groups, especially American Indians, some Asian Americans (e.g., of south Asian ancestry), and some Hispanics (e.g., Puerto Ricans), and may overestimate the risk for others, including some Asian Americans (e.g., of east Asian ancestry) and some Hispanics (e.g., Mexican Americans).
Because the primary use of these risk estimates is to facilitate the very important discussion regarding risk reduction through lifestyle change, the imprecision introduced is small enough to justify proceeding with lifestyle change counseling informed by these results.

Disclaimer

The results and recommendations provided by this application are intended to inform but do not replace clinical judgment. Therapeutic options should be individualized and determined after discussion between the patient and their care provider.

  Therapy Impact
Potential risk reduction impact of different therapies can only be calculated for patients at an initial visit.
  Therapy Impact
Potential risk reduction impact of different therapies can only be calculated for patients at an initial visit.

Resources

Clinician Resources

Patient Resources

Patient Scenario

Initial visit: A 70-year-old black man presents for an initial visit to consider prevention of atherosclerotic cardiovascular disease (ASCVD). A friend recently had a stroke and he is concerned that he may be at risk as well.

  • Past medical history: Bleeding duodenal ulcer 10 years ago.
  • ASCVD risk factors: Current smoker, ½ pack per day for 50 years; no history of diabetes mellitus.
  • Current medications: None.
  • Physical examination: Systolic blood pressure 160 mm Hg; no signs of ASCVD.
  • Lab data: Total cholesterol 240 mg/dL, HDL-cholesterol 40 mg/dL, triglycerides 150 mg/dL, LDL-cholesterol 170 mg/dL.

The clinician engages him in a discussion regarding his risks for ASCVD, and the potential for risk reduction. The clinician begins by estimating the patient’s 10-year risk for ASCVD based on his current risk profile. After entering the patient’s current data in the Estimate screen of the ASCVD Risk Estimator Plus app, the clinician and patient review the fact that the estimated 10-year risk is 30.8%. The clinician explains that this means that if we had 100 men like him, at the end of 10 years, about 31 of them will have had or died from a heart attack or stroke. This is considered to be a high-risk scenario by current clinical practice guidelines. The patient expresses a desire to lower his risk.
The clinician provides important information to the patient about pursuing therapeutic lifestyle changes using the Lifestyle table on the Advice tab, including a heart healthy diet and regular physical activity. He agrees to focus on reducing calorie intake, limiting sodium intake, and to start a walking program for 20 minutes daily. Together, they review options for smoking cessation.
Using the Therapy Impact tab in the ASCVD Risk Estimator Plus app, they review medications that may help reduce the patient’s risk. They note that, on average, starting a moderate intensity statin or blood pressure lowering therapy alone, or stopping smoking for 2 years, would each reduce his 10-year risk to about 23%, whereas aspirin alone would reduce the risk to about 28% (with possible risk of bleeding, in light of his history). Starting a statin and blood pressure lowering therapy plus smoking cessation could cut his 10-year risk to as little as 12%. The clinician and patient review the bar graph on the advice tab to visualize all these options together.
The patient is uncertain about whether he is ready to adhere to all of these interventions concurrently. Given the patient’s particular interest in reducing stroke risk, and his current hypertension, the patient and clinician decide to pursue blood pressure lowering therapy with a calcium channel blocker, and to pursue smoking cessation with pharmacological assistance. They agree to discuss the use of aspirin or statins at a future visit, which is scheduled.


Follow-up Visit: One year later, the patient returns for a follow-up visit, having had an interim visit at which his blood pressure regimen was adjusted with the addition of a thiazide diuretic. He successfully stopped smoking 8 months ago. His lipids are unchanged from baseline. His systolic blood pressure today is 140 mm Hg.
However, with his greater than expected blood pressure reduction and successful smoking cessation, the clinician calculates the patient’s updated risk by entering both the patient’s initial visit and follow up data into the app’s Estimate tab, and determines his risk is now 11.4%. The clinician congratulates the patient, and asks whether he would like to consider initiating moderate-intensity statin therapy. They consider the pros and cons and the patient’s preferences, and elect to pursue a moderate intensity statin, with plans to assess the patient’s LDL-cholesterol response in 3 months. The clinician emails themselves a summary of the visit and the patient’s progress to keep in their record, using the button on the Advice tab.

Understanding Cardiovascular Risk

10-Year ASCVD Risk

  • The 10-year calculated ASCVD risk is a quantitative estimation of absolute risk based upon data from representative population samples.
  • The 10-year risk estimate for "optimal risk factors" is represented by the following specific risk factor numbers for an individual of the same age, sex and race: Total cholesterol of ≤ 170 mg/dL, HDL-cholesterol of ≥ 50 mg/dL, untreated systolic blood pressure of ≤ 110 mm Hg, no diabetes history, and not a current smoker.
  • While the risk estimate is applied to individuals, it is based on group averages.
  • Just because two individuals have the same estimated risk does not mean that they will or will not have the same event of interest.
  • Example: If the 10-year ASCVD risk estimate is 10%, this indicates that among 100 patients with the entered risk factor profile, 10 would be expected to have a heart attack or stroke in the next 10 years.

Lifetime ASCVD Risk

  • The lifetime calculated ASCVD risk represents a quantitative estimation of absolute risk for a 50 year old man or woman with the same risk profile.
  • This estimation of risk is based on the grouping of risk factor levels into 5 strata.
    • All risk factors are optimal*
    • ≥1 risk factors are not optimal†
    • ≥1 risk factors are elevated‡
    • 1 major risk factor§
    • ≥2 major risk factors§
  • The division of lifetime risk by these 5 strata leads to thresholds in the data with large apparent changes in lifetime risk estimates.
  • Example: An individual that has all optimal risk factors except for a systolic blood pressure of 119 mm Hg has a lifetime ASCVD risk of 5%. In contrast, a similar individual that has all optimal risk factors except for a systolic blood pressure of 120 mm Hg has a lifetime ASCVD risk of 36%. This substantial difference in lifetime risk is due to the fact that they are in different stratum.

*Optimal risk levels for lifetime risk are represented by the simultaneous presence of all of the following: Untreated total cholesterol <180 mg/dL, untreated blood pressure <120/<80 mm Hg, no diabetes history, and not a current smoker

†Nonoptimal risk levels for lifetime risk are represented by 1 or more of the following: Untreated total cholesterol of 180 to 199 mg/dL, untreated systolic blood pressure of 120 to 139 mm Hg or diastolic blood pressure of 80 to 89 mm Hg, and no diabetes history and not a current smoker

‡Elevated risk levels for lifetime risk are represented by 1 or more of the following: Untreated total cholesterol of 200 to 239 mg/dL, untreated systolic blood pressure of 140 to 159 mm Hg or diastolic blood pressure of 90 to 99 mm Hg, and no diabetes history and not a current smoker

§Major risk levels for lifetime risk are represented by any of the following: Total cholesterol ≥240 mg/dL or treated, systolic blood pressure ≥160 mm Hg or diastolic blood pressure ≥100 mm Hg or treated, or diabetes, or current smoker

Diet recommendations

Diet recommendations for LDL-C lowering

  1. Consume a dietary pattern that emphasizes intake of vegetables, fruits, and whole grains; includes low-fat dairy products, poultry, fish, legumes, non-tropical vegetable oils and nuts; and limits intake of sweets, sugar-sweetened beverages, and red meats. (I A)
    • Adapt this dietary pattern to appropriate calorie requirements, personal and cultural food preferences, and nutrition therapy for other medical conditions (including diabetes mellitus).
    • Achieve this pattern by following plans such as the DASH dietary pattern, the USDA Food Pattern, or the AHA Diet.
  2. Aim for a dietary pattern that achieves 5-6% of calories from saturated fat. (I A)
  3. Reduce percent of calories from saturated fat. (I A)
  4. Reduce percent of calories from trans fat. (I A)

Diet recommendations for blood pressure lowering

  1. Consume a dietary pattern that emphasizes intake of vegetables, fruits, and whole grains; includes low-fat dairy products, poultry, fish, legumes, non-tropical vegetable oils and nuts; and limits intake of sweets, sugar-sweetened beverages, and red meats. (I A)
    • Adapt this dietary pattern to appropriate calorie requirements, personal and cultural food preferences, and nutrition therapy for other medical conditions (including diabetes mellitus).
    • Achieve this pattern by following plans such as the DASH dietary pattern, the USDA Food Pattern, or the AHA Diet.
  2. Lower sodium intake. (I A)
  3. Consume no more than 2400 mg of sodium per day. (I B)

Weight Management Recommendations

Diets for weight loss

  1. Prescribe a diet to achieve reduced calorie intake for obese or overweight individuals who would benefit from weight loss, as part of a comprehensive lifestyle intervention with 1 of the following (I A):
    • 1200-1500 kcal/day for women and 1500-1800 kcal/day for men.
    • 500-750 kcal/day energy deficit.
    • Use one of the evidence-based diets that restricts certain food types (e.g., high-carbohydrate foods, low-fiber foods, or high-fat foods) in order to create an energy deficit by reduced food intake.
  2. Prescribe a calorie-restricted diet for obese or overweight individuals who would benefit from weight loss, based on the patient's preferences and health status, and preferably refer to a nutrition professional for counseling. (I A)

Lifestyle interventions and counseling for weight loss

  1. Advise participation in a comprehensive lifestyle program that assists participants in adhering to a lower calorie diet and increasing physical activity through the use of behavioral strategies. (I A)
  2. Prescribe on site, high-intensity (i.e., ≥14 sessions in 6 months) comprehensive weight loss interventions provided in individual or group sessions by a trained interventionist. (I A)
  3. Consider prescription of electronically delivered weight loss programs (including by telephone) that includes personalized feedback from a trained interventionist, recognizing that it may result in smaller weight loss than face-to-face interventions. (IIa A)
  4. Consider some commercial-based programs that provide comprehensive lifestyle interventions, provided there is peer-reviewed published evidence of their safety and efficacy. (IIa A)
  5. Consider a very low calorie diet (<800 kcal/day) only in limited circumstances and only when provided by trained practitioners in a medical care setting where medical monitoring and high intensity lifestyle intervention can be provided. (IIa A)
  6. Advise individuals who have lost weight to participate long term (≥1 year) in a comprehensive weight loss maintenance program. (I A)
  7. Prescribe face-to-face or telephone-delivered weight loss maintenance programs that provide regular contact (> monthly) with a trained interventionist who helps participants engage in high levels of physical activity (i.e., 200-300 minutes/week), monitor body weight regularly (> weekly), and consume a reduced-calorie diet (need to lower body weight). (I A)

Selection criteria for bariatric surgical treatment of obesity

  1. Advise adults with a BMI ≥40 kg/m2 or BMI ≥35 kg/m2 with obesity-related co-morbid conditions who are motivated to lose weight and who have not responded to behavioral treatment with or without pharmacotherapy with sufficient weight loss to achieve targeted health outcome goals that bariatric surgery may be an appropriate option to improve health and offer referral to an experienced bariatric surgeon for consultation and evaluation. (IIa A)

Physical Activity Recommendations

Physical activity recommendations for modifying lipids and blood pressure lowering

  1. Advise adults to engage in aerobic physical activity to reduce LDL-cholesterol, non-HDL-cholesterol, and blood pressure. (IIa A)
    • Frequency: 3-4 sessions a week
    • Intensity: Moderate to vigorous
    • Duration: 40 minutes on average

Physical activity recommendations for secondary prevention*

  1. Aerobic exercise
    • Frequency: 3-5 days/week
    • Intensity: 50-80% of exercise capacity
    • Duration: 20-60 minutes
    • Modalities: Examples include walking, treadmill, cycling, rowing, stair climbing, and arm/leg ergometry
  2. Resistance exercise
    • Frequency: 2-3 days/week
    • Intensity: 10-15 repetitions/set to moderate fatigue
    • Duration: 1-3 sets of 8-10 upper and lower body exercises
    • Modalities: Examples include calisthenics, elastic bands, cuff/hand weights, dumbbells, free weights, wall pulleys, and weight machines
*Balady GJ et al. Core components of cardiac rehabilitation/secondary prevention programs: 2007 update: a Scientific Statement of the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation 2007;115:2675-2682

Tobacco Cessation Recommendations

5 R's for patients not ready to quit

  1. Relevance—Encourage the patient to indicate why quitting is personally relevant.
  2. Risks—Ask the patient to identify potential negative consequences of tobacco use.
  3. Rewards—Ask the patient to identify potential benefits of stopping tobacco use.
  4. Roadblocks—Ask the patient to identify barriers or impediments to quitting.
  5. Repetition—The motivational intervention should be repeated every time an unmotivated patient has an interaction with a clinician. Tobacco users who have failed in previous quit attempts should be told that most people make repeated quit attempts before they are successful.

5 A's for patients that are ready to quit

  1. Ask—Systematically identify all tobacco users at every visit.
  2. Advise—Strongly urge all smokers to quit.
  3. Assess—Identify smokers willing to make a quit attempt.
  4. Assist—Aid the patient in quitting.
  5. Arrange—Schedule follow-up contact.

Groups that Benefit from Statin Therapy

1. Secondary Prevention: Clinical ASCVD

Clinical ASCVD includes acute coronary syndromes, history of MI, stable or unstable angina, coronary or other arterial revascularization, stroke, TIA, or peripheral arterial disease presumed to be of atherosclerotic origin.

High-intensity statin therapy should be initiated or continued as first-line therapy in women and men ≤75 years of age who have clinical ASCVD, unless contraindicated. (I A)

In individuals with clinical ASCVD in whom high-intensity statin therapy would otherwise be used, when high-intensity statin therapy is contraindicated or when characteristics predisposing to statin-associated adverse effects are present, moderate-intensity statin should be used as the second option if tolerated. (I A)

In individuals with clinical ASCVD >75 years of age, it is reasonable to evaluate the potential for ASCVD risk-reduction benefits and for adverse effects, drug-drug interactions and to consider patient preferences, when initiating a moderate- or high-intensity statin. It is reasonable to continue statin therapy in those who are tolerating it. (IIa B)

2. Primary Prevention: LDL-C ≥190 mg/dL

Individuals with LDL-C ≥190 mg/dL or triglycerides ≥500 mg/dL should be evaluated for secondary causes of hyperlipidemia. (I B)

Adults ≥21 years of age with primary LDL-C ≥190 mg/dL should be treated with high-intensity statin therapy unless contraindicated. For individuals unable to tolerate high-intensity statin therapy, use the maximum tolerated statin intensity. (I B)

For individuals ≥21 years of age with an untreated primary LDL-C ≥190 mg/dL, it is reasonable to intensify statin therapy to achieve at least a 50% LDL-C reduction. (IIa B)

For individuals ≥21 years of age with an untreated primary LDL-C ≥190 mg/dL, after the maximum intensity of statin therapy has been achieved, addition of a nonstatin drug may be considered to further lower LDL-C. Evaluate the potential for ASCVD risk reduction benefits, adverse effects, drug-drug interactions, and consider patient preferences. (IIb C)

3. Primary Prevention: Diabetes and aged 40 to 75 years with LDL-C between 70 - 189 mg/dL

Moderate-intensity statin therapy should be initiated or continued for adults 40 to 75 years of age with diabetes mellitus. (I A)

High-intensity statin therapy is reasonable for adults 40 to 75 years of age with diabetes mellitus with a ≥7.5% estimated 10-year ASCVD risk unless contraindicated. (IIa B)

In adults with diabetes mellitus, who are <40 or >75 years of age, it is reasonable to evaluate the potential for ASCVD benefits and for adverse effects, for drug-drug interactions, and to consider patient preferences when deciding to initiate, continue, or intensify statin therapy. (IIa C)

4. Primary Prevention: No diabetes and estimated 10-year ASCVD risk of ≥7.5% who are between 40 to 75 years of age with LDL-C between 70 - 189 mg/dL

The Pooled Cohort Equations should be used to estimate 10-year ASCVD risk for individuals with LDL-C 70 to 189 mg/dL without clinical ASCVD to guide initiation of statin therapy for the primary prevention of ASCVD. (I B)

Before initiating statin therapy for the primary prevention of ASCVD in adults with LDL-C 70 - 189 mg/dL without clinical ASCVD or diabetes it is reasonable for clinicians and patients to engage in a discussion which considers the potential for ASCVD risk reduction benefits and for adverse effects, for drug-drug interactions, and patient preferences for treatment. (IIa C)

Adults 40 to 75 years of age with LDL-C 70 to 189 mg/dL, without clinical ASCVD or diabetes and an estimated 10-year ASCVD risk ≥7.5% should be treated with moderate- to high-intensity statin therapy. (I A)

It is reasonable to offer treatment with a moderate-intensity statin to adults 40 to 75 years of age, with LDL-C 70 to 189 mg/dL, without clinical ASCVD or diabetes and an estimated 10-year ASCVD risk of 5% to <7.5%. (IIa B)

In adults with LDL-C <190 mg/dL who are not otherwise identified in a statin benefit group, or for whom after quantitative risk assessment a risk-based treatment decision is uncertain, additional factors may be considered to inform treatment decision making. In these individuals, statin therapy for primary prevention may be considered after evaluating the potential for ASCVD risk reduction benefits, adverse effects, drug-drug interactions, and discussion of patient preferences. (IIb C)

Additional Factors

These factors may include:

Statin benefit may be less clear in other groups; additional factors may be considered to inform treatment decision making.

  1. 5 to <7.5% 10-year ASCVD risk
  2. Primary LDL-C ≥160 mg/dL or other evidence of genetic hyperlipidemias
  3. Family history of premature ASCVD
  4. High sensitivity C-reactive protein ≥2 mg/L
  5. Coronary artery calcium score ≥300 Agatston units or ≥75th percentile for age, sex, and ethnicity
  6. Ankle-brachial index <0.9
  7. Lifetime risk of ASCVD

Blood Cholesterol Recommendation Summary

Recommendations REC
Click here for Definitions of Statin Intensity
ACC/ AHA ACC/AHA COR ACC/ AHA ACC/AHA LOE
A. Heart-healthy lifestyle habits should be encouraged for all individuals.
B . The appropriate intensity of statin therapy should be initiated or continued:
1. Clinical ASCVD*
a. Age ≤75 y and no safety concerns: High-intensity statin I A
b. Age >75 y or safety concerns: Moderate-intensity statin I A
2. Primary prevention – Primary LDL–C ≥190 mg/dL
a. Rule out secondary causes of hyperlipidemia
b. Age ≥21y: High-intensity statin I B
c. Achieve at least a 50% reduction in LDL–C IIa B
d. LDL–C lowering nonstatin therapy may be considered to further reduce LDL–C IIb C
3. Primary prevention – Diabetes 40-75 years of age and LDL–C 70-189 mg/dL
a. Moderate-intensity statin I A
b. Consider high-intensity statin when ≥7.5% 10-y ASCVD risk using the Pooled Cohort Equations† IIa B
4. Primary prevention – No diabetes 40-75 years of age and LDL–C 70-189 mg/dL
a. Estimate 10-y ASCVD risk using the Risk Calculator based on the Pooled Cohort Equations† in those NOT receiving a statin; estimate risk every 4-6 y I B
b. To determine whether to initiate a statin, engage in a clinician-patient discussion of the potential for ASCVD risk reduction, adverse effects, drug-drug interactions, and patient preferences. IIa C
c. Re-emphasize heart-healthy lifestyle habits and address other risk factors.
i. ≥7.5% 10-y ASCVD risk: Moderate- or high-intensity statin I A
ii. 5 to <7.5% 10-y ASCVD risk: Consider moderate-intensity statin IIa B
iii. Other factors may be considered‡: LDL–C ≥160 mg/dL, family history of premature cardiovascular disease, hs-CRP ≥2.0 mg/L, CAC score ≥300 Agaston units, ABI <0.9 or lifetime ASCVD risk IIb C
5. Primary prevention when LDL–C <190 mg/dL and age <40 or >75 y, or <5% 10-y ASCVD risk
a. Statin therapy may be considered in selected individuals‡ IIb C
6. Statin therapy is not routinely recommended for individuals with NYHA class II-IV heart failure or who are receiving maintenance hemodialysis
C. Regularly monitor adherence to lifestyle and drug therapy with lipid and safety assessments.
1. Assess adherence, response to therapy, and adverse effects within 4-12 wk following statin initiation or change in therapy. I A
a. Measure a fasting lipid panel I A
b. Do not routinely monitor ALT or CK unless symptomatic IIa C
c. Screen and treat type 2 diabetes according to current practice guidelines. Heart-healthy lifestyle habits should be encouraged to prevent progression to diabetes I B
d. Anticipated therapeutic response approximately ≥50% reduction in LDL–C from baseline for high-intensity statin and 30% to <50% for moderate-intensity statin IIa B
i. Insufficient evidence for LDL–C or non-HDL-C treatment targets from RCTs
ii. For those with unknown baseline LDL–C, an LDL–C <100 mg/dL was observed in RCTs of high-intensity statin therapy
e. Less than anticipated therapeutic response:
i. Reinforce improved adherence to lifestyle and drug therapy I A
ii. Evaluate for secondary causes of hyperlipidemia if indicated I A
iii. Increase statin intensity, or if on maximally-tolerated statin intensity, consider addition of nonstatin therapy in selected high-risk individuals§ IIb C
f. Regularly monitor adherence to lifestyle and drug therapy every 3-12 mo once adherence has been established. Continued assessment of adherence for optimal ASCVD risk reduction and safety. I A
D. In individuals intolerant of the recommended intensity of statin therapy, use the maximally-tolerated intensity of statin. I B
1. If there are muscle or other symptoms, establish that they are related to the statin IIa B
2. For specific recommendations on managing muscle symptoms (see Statin Safety Recommendations)

* Clinical ASCVD includes acute coronary syndromes, history of MI, stable or unstable angina, coronary or other arterial revascularization, stroke, TIA, or peripheral arterial disease presumed to be of atherosclerotic origin.

Estimated 10-year or "hard" ASCVD risk includes first occurrence of nonfatal MI, CHD death, and nonfatal and fatal stroke as used by the Risk Assessment Work Group in developing the Pooled Cohort Equations.

These factors may include primary LDL–C ≥160 mg/dL or other evidence of genetic hyperlipidemias; family history of premature ASCVD with onset <55 years of age in a first-degree male relative or <65 years of age in a first-degree female relative; hs-CRP ≥2 mg/L; CAC score ≥300 Agatston units or ≥75 th percentile for age, sex, and ethnicity; ABI <0.9; or lifetime risk of ASCVD. Additional factors that might aid in individual risk assessment could be identified in the future.

§ High-risk individuals include those with clinical ASCVD, an untreated LDL–C ≥190 mg/dL suggesting genetic hypercholesterolemia, or diabetes.

ABI indicates ankle-brachial index; ACC, American College of Cardiology; AHA, American Heart Association; ALT, alanine aminotransferase, a test of hepatic function; ASCVD, atherosclerotic cardiovascular disease; CAC, coronary artery calcium; CHD, coronary heart disease; CK, creatine kinase, a test of muscle injury; COR, Class of Recommendation; HDL-C, high-density lipoprotein cholesterol; hs-CRP, high-sensitivity C-reactive protein; LDL–C, low-density lipoprotein cholesterol; LOE, Level of Evidence; NHLBI, National Heart, Lung, and Blood Institute; NYHA, New York Heart Association; RCTs, randomized controlled trials; and TIA, transient ischemic attack.

Recommendations for Initiation of Statin Therapy

infographic on statin therapy

This flow diagram is intended to serve as an easy reference guide summarizing recommendations for ASCVD risk assessment and treatment. Assessment of the potential for benefit and risk from statin therapy for ASCVD prevention provides the framework for clinical decision making incorporating patient preferences.

* Percent reduction in LDL–C can be used as an indication of response and adherence to therapy, but is not in itself a treatment goal.

The Pooled Cohort Equations can be used to estimate 10-year ASCVD risk in individuals with and without diabetes. The estimator within this application should be used to inform decision making in primary prevention patients not on a statin.

Consider moderate-intensity statin as more appropriate in low-risk individuals.

§ For those in whom a risk assessment is uncertain, consider factors such as primary LDL–C ≥160 mg/dL or other evidence of genetic hyperlipidemias, family history of premature ASCVD with onset <55 years of age in a first-degree male relative or <65 years of age in a first-degree female relative, hs-CRP ≥2 mg/L, CAC score ≥300 Agatston units, or ≥75th percentile for age, sex, and ethnicity (for additional information, see http://www.mesa-nhlbi.org/CACReference.aspx), ABI <0.9, or lifetime risk of ASCVD. Additional factors that may aid in individual risk assessment may be identified in the future.

|| Potential ASCVD risk-reduction benefits. The absolute reduction in ASCVD events from moderate- or high-intensity statin therapy can be approximated by multiplying the estimated 10-year ASCVD risk by the anticipated relative risk reduction from the intensity of statin initiated (~30% for moderate-intensity statin or ~45% for high-intensity statin therapy). The net ASCVD risk reduction benefit is estimated from the number of potential ASCVD events prevented with a statin compared to the number of potential excess adverse events.

Potential adverse effects. The excess risk of diabetes is the main consideration in ~0.1 excess cases per 100 individuals treated with a moderate-intensity statin for 1 year and ~0.3 excess cases per 100 individuals treated with a high-intensity statin for 1 year. In RCTs, both statin-treated and placebo-treated participants experienced the same rate of muscle symptoms. The actual rate of statin-related muscle symptoms in the clinical population is unclear. Muscle symptoms attributed to statin therapy should be evaluated (see Statin Safety Recommendations).

ABI indicates ankle-brachial index; ASCVD, atherosclerotic cardiovascular disease; CAC, coronary artery calcium; hs-CRP, high-sensitivity C-reactive protein; LDL–C, low-density lipoprotein cholesterol; MI, myocardial infarction; RCT, randomized controlled trial.

Intensities of Statin Therapy

Low-Intensity

Daily dose lowers LDL-C, on average by approximately <30%

dose

Moderate-Intensity

Daily dose lowers LDL-C, on average by approximately 30% to <50%

dose

High-Intensity

Daily dose lowers LDL-C, on average by approximately ≥50%

dose

Statins and doses that are approved by the U.S. FDA but were not tested in the RCTs reviewed are listed in parentheses

* Evidence from 1 RCT (down-titration if unable to tolerate atorvastatin 80 mg)

** Initiation of or titration to simvastatin 80 mg is not recommended by the FDA due to increased risk of myopathy, including rhabdomyolysis

Recommendations to Monitor Response to Statin Therapy

infographic on statin therapy

*Fasting lipid panel preferred. In a nonfasting individual, a non–HDL–C ≥ 220 mg/dL may indicate genetic hypercholesterolemia that requires further evaluation or a secondary etiology. If nonfasting triglycerides are ≥ 500 mg/dL, a fasting lipid panel is required.

In those already on a statin, in whom baseline LDL–C is unknown, an LDL–C <100 mg/dL was observed in most individuals receiving high-intensity statin therapy in RCTs.

Refer to Statin Safety Recommendations

Statin Safety Recommendations

Statin Selection

To maximize the safety of statins, selection of the appropriate statin and dose in men and nonpregnant/nonnursing women should be based on patient characteristics, level of ASCVD risk, and potential for adverse effects.

Moderate-intensity statin therapy should be used in individuals in whom high-intensity statin therapy would otherwise be recommended when characteristics predisposing them to statin associated adverse effects are present.

Characteristics predisposing individuals to statin adverse effects include, but are not limited to: (I B)

  • Multiple or serious comorbidities, including impaired renal or hepatic function.
  • History of previous statin intolerance or muscle disorders.
  • Unexplained ALT elevations ≥3 times ULN.
  • Patient characteristics or concomitant use of drugs affecting statin metabolism.
  • >75 years of age.

Additional characteristics that may modify the decision to use higher statin intensities may include, but are not limited to:

  • History of hemorrhagic stroke.
  • Asian ancestry.

Statin Dosage

  • Decreasing the statin dose may be considered when 2 consecutive values of LDL-C levels are <40 mg/dL. (IIb C)
  • It may be harmful to initiate simvastatin at 80 mg daily or increase the dose of simvastatin to 80 mg daily. (III A)

Creatine Kinase (CK)

  • CK should not be routinely measured in individuals receiving statin therapy. (III A)
  • Baseline measurement of CK is reasonable for individuals believed to be at increased risk for adverse muscle events based on a personal or family history of statin intolerance or muscle disease, clinical presentation, or concomitant drug therapy that might increase the risk for myopathy. (IIa C)
  • During statin therapy, it is reasonable to measure CK in individuals with muscle symptoms, including pain, tenderness, stiffness, cramping, weakness, or generalized fatigue. (II C)

Muscle Symptoms

It is reasonable to evaluate and treat muscle symptoms, including pain, tenderness, stiffness, cramping, weakness, or fatigue, in statin-treated patients according to the following management algorithm: (IIa B)

  • To avoid unnecessary discontinuation of statins, obtain a history of prior or current muscle symptoms to establish a baseline before initiating statin therapy.
  • If unexplained severe muscle symptoms or fatigue develop during statin therapy, promptly discontinue the statin and address the possibility of rhabdomyolysis by evaluating CK, creatinine, and a urinalysis for myoglobinuria.
  • If mild to moderate muscle symptoms develop during statin therapy:
    • Discontinue the statin until the symptoms can be evaluated.
    • Evaluate the patient for other conditions that might increase the risk for muscle symptoms (e.g., hypothyroidism, reduced renal or hepatic function, rheumatologic disorders such as polymyalgia rheumatica, steroid myopathy, vitamin D deficiency, or primary muscle diseases).
    • If muscle symptoms resolve, and if no contraindication exists, give the patient the original or a lower dose of the same statin to establish a causal relationship between the muscle symptoms and statin therapy.
    • If a causal relationship exists, discontinue the original statin. Once muscle symptoms resolve, use a low dose of a different statin.
    • Once a low dose of a statin is tolerated, gradually increase the dose as tolerated.
    • If, after 2 months without statin treatment, muscle symptoms or elevated CK levels do not resolve completely, consider other causes of muscle symptoms listed above.
    • If persistent muscle symptoms are determined to arise from a condition unrelated to statin therapy, or if the predisposing condition has been treated, resume statin therapy at the original dose.

Hepatic Function

  • Baseline measurement of hepatic transaminase levels (ALT) should be performed before initiating statin therapy. (I B)
  • During statin therapy, it is reasonable to measure hepatic function if symptoms suggesting hepatotoxicity arise (e.g., unusual fatigue or weakness, loss of appetite, abdominal pain, dark colored urine or yellowing of the skin or sclera). (IIa C)

Diabetes

Individuals receiving statin therapy should be evaluated for new-onset diabetes mellitus according to the current diabetes screening guidelines. Those who develop diabetes mellitus during statin therapy should be encouraged to adhere to a heart healthy dietary pattern, engage in physical activity, achieve and maintain a healthy body weight, cease tobacco use, and continue statin therapy to reduce their risk of ASCVD events. (I B)

Age and Drug Regimen Consideration

For individuals taking any dose of statins, it is reasonable to use caution in individuals >75 years of age, as well as in individuals that are taking concomitant medications that alter drug metabolism, taking multiple drugs, or taking drugs for conditions that require complex medication regimens (e.g., those who have undergone solid organ transplantation or are receiving treatment for HIV). A review of the manufacturer's prescribing information may be useful before initiating any cholesterol-lowering drug. (IIa C)

Cognitive Impairment

For individuals presenting with a confusional state or memory impairment while on statin therapy, it may be reasonable to evaluate the patient for nonstatin causes, such as exposure to other drugs, as well as for systemic and neuropsychiatric causes, in addition to the possibility of adverse effects associated with statin drug therapy. (IIb C)

Terms and Concepts

ASCVD:atherosclerotic cardiovascular disease, defined as coronary death or nonfatal myocardial infarction, or fatal or nonfatal stroke

ABCS Therapies: Aspirin therapy in appropriate patients, Blood pressure control, Cholesterol management, and Smoking cessation

Initial Visit:

- First time a patient undergoes an ASCVD risk assessment with a particular clinician and initiates a discussion regarding the benefits of starting (or intensifying) therapy with aspirin, blood pressure lowering medication, cholesterol lowering medication, and/or smoking/tobacco cessation (ABCS) as part of a risk-reduction plan. The 10-year ASCVD risk determined at the initial visit should also be used as a benchmark with which to compare updated risk at follow-up visit.

- The patient may have already initiated any of the ABCS therapies prior to the initial visit, individually or in combination.

10-year ASCVD risk calculated at the initial visit, without comparison to a previous visit:

- The initial 10-year ASCVD Risk serves as a baseline or reference-point risk. The patient parameters used to calculate are also needed to calculate a representative follow-up risk, and the initial risk value itself serves as a comparison point for follow up risk.

Follow Up Visit:Any visit after the established initial visit at which an updated 10-year ASCVD risk is calculated based on updated clinical and laboratory values.

Optimal Risk:Predicted 10-year ASCVD risk for someone with the same age and race/ethnicity category who has an optimal risk factor profile (total cholesterol, 170 mg/dL; HDL-cholesterol, 60 mg/d; SBP, 110 mm Hg; nonsmoker; non-diabetic; and no blood pressure–lowering drugs).

Smokers:For the purposed of this app, smokers are defined as cigarette smokers in accordance with the patient populations studied in the relevant clinical trials used to develop the tool. Clinical judgement should be exercised in the case of patient’s who use e-cigarettes and other nicotine and tobacco products.

Lifestyle:AHA/ACC guidelines stress the importance of lifestyle modifications as the foundation to lowering cardiovascular disease risk. These include eating a heart-healthy diet, regular aerobic exercises, maintenance of desirable body weight and avoidance of tobacco products. The evidence base for this specific tool focused on average patient responses to the ABCS therapies (aspirin when appropriate, blood pressure control, cholesterol management, and smoking cessation). Evidence for quantification of benefit from individual therapeutic lifestyle interventions is currently lacking and was out of the scope for this tool. However, the tool is intended to guide decision-making around ABCS in the context of, and in addition to, recommended lifestyle interventions. Benefit from lifestyle intervention is reflected in the app’s updated 10-year risk calculation at a follow up visit through the “credit” given for improvement of patient’s LDL-C and/or systolic blood pressure, regardless of how that improvement was achieved.

How are the different risk values in the app calculated?

Lifetime ASCVD Risk:

Estimates of lifetime risk for ASCVD are provided for adults 20 through 59 years of age and are shown as the lifetime risk for ASCVD for a 50-year old without ASCVD who has the risk factor values entered at the initial visit. Because the primary use of these lifetime risk estimates is to facilitate the very important discussion regarding risk reduction through lifestyle change, the imprecision introduced is small enough to justify proceeding with lifestyle change counseling informed by these results.

Estimated 10 Year ASCVD Risk

At Initial Visit (without comparison to a previous visit): Calculated using the ACC/AHA 2013 Pooled Cohort Equation, which predict the absolute 10-year risk for an ASCVD for a patient with the profile entered at initial visit. This is the same as the previous version of the ASCVD Risk Estimator app.

At Follow-up visit (with comparison to a previous visit): Updated 10-year risk for ASCVD is a function of the initial visit risk, the follow-up age, and the interim change in therapies and risk factor levels, which are themselves a function of response to therapy and adherence. The confidence of the updated on-treatment risk estimate is improved by scaling the risk reduction to the amount of change in SBP or LDL-cholesterol or duration of smoking cessation. The values for the actual updated 10-year ASCVD risk estimate also have floor and ceiling values applied. The floor value is calculated as the predicted 10-year ASCVD risk for someone with optimal risk factor levels at the follow-up age. A patient’s 10-year risk at follow up will not be calculated to a value below this floor value. The ceiling value is the predicted 10-year ASCVD risk calculated from the actual updated risk factor profile, including use of medications.

Projected 10 Year ASCVD Risk on the Therapy Impact Tab
Numbers on Therapy Impact mode represent the projected 10-year ASCVD risk that would be associated with institution of specific preventive therapies as designated for each row by the scenarios selected by the user. These estimates are a function of the initial visit predicted 10-year risk from for the patient and the expected average relative risk reduction associated with a given therapy experienced by participants in randomized clinical trials, using systematic review data described in the original Million Hearts Longitudinal ASCVD Risk Assessment Tool manuscript. In instances where a therapy is not advised or relevant for a given patient based on the profile entered (smoking cessation for a patient who has never smoked), the forecasted risk for this therapy will be displayed as “NA”. See below for more information about individual therapies.

What effect do the different ABCS therapies and related risk factors have on the calculations in the app?

Systolic Blood Pressure and Blood Pressure Medications

  • Risk reduction estimates related to blood pressure medication come from randomized controlled trials that have tended to last for 3 to 5 years, so it is assumed that patients who would start a blood pressure medication would stay on it for at least that period of time, and adhere to the therapy similarly to participants in the trials.
  • If follow up risk is estimated for a patient who has not yet initiated blood pressure medication, and then a forecasted risk is calculated with the initiation of BP meds, the user may see the patient’s risk actually increase. This is because the app is forecasting what the patient’s risk would be if they had achieved the same blood pressure reduction they’ve already achieved, but with the aid of medication, and the calculation gives more “credit” for blood pressure reduction without the aid of medication than with. This same principle applies to the initial visit 10-year risk calculation.
  • In terms for forecasting, for patients already taking blood pressure–lowering drugs, one can estimate the expected effect of additional medication. However, if a patient has an initial visit SBP <120 mm Hg, or <130 mm Hg with diabetes mellitus, no additional benefit of SBP lowering is assumed.

LDL-C and Statin Therapy

  • As an update to the original ASCVD Risk Estimator, “Initial 10 year ASCVD risk may be calculated for patients who have already initiated statin therapy because recent evidence suggests a patient’s cholesterol values have the same the impact on ASCVD risk regardless of whether current values were achieved with or without the aid of statin therapy. However, the specific LDL-C value and statin use status at initial visit does still does not affect the initial visit 10-year risk calculation itself. They are only collected at initial visit to provide context for the forecasted risk reduction and to provide baseline values for updating ASCVD risk at follow-up visits.
  • Patients with LDL-cholesterol of at least 190 mg/dL may have familial hypercholesterolemia and should be evaluated and considered for statin therapy regardless of age and estimated 10-year ASCVD risk.
  • Risk reduction estimates related to statin therapy come from randomized controlled trials that have tended to last for 3 to 5 years, so it is assumed that patients who would start satin therapy would stay on it for at least that period of time, and adhere to the therapy similarly to participants in the trials.
  • For patients with estimated 10-year ASCVD risk below 5%, users will see “NA” appear in initial visit forecast scenarios where statin use or intensification would be added, given that the guidelines do not recommend consideration of statin therapy for this group.

Aspirin Use

  • Aspirin use status does not affect the initial visit 10-year risk calculation itself, but is collected at initial visit to provide context for the forecasted risk reduction and to provide baseline values for updating ASCVD risk at follow-up visits.
  • If the patient is taking aspirin therapy at initial visit, the expected risk reduction for continuing aspirin is assumed to be the same as starting aspirin de novo, because it is uncertain how to quantify any increase in risk associated with aspirin cessation.
  • For initial visit forecasting, patients with estimated 10- year ASCVD risk below 10%, users will see “NA” appear in rows where aspirin would be started because guidelines do not typically recommend consideration of aspirin therapy for patients with 10-year risk <10%.

Smokers and Smoking Cessation

  • The app calculations are based on studies that estimated the time-dependent effects of successful smoking cessation on ASCVD risk reduction (See the original Million Hearts Longitudinal ASCVD Risk Assessment Tool manuscript). As a result, the combined estimates for risk reduction associated with smoking cessation are 15% at 1 year, 27% at 2 years, 38% at 3 years, and 47% at 4 years. Because the risk reduction estimates for aspirin, blood pressure–lowering, and statins were based on trials with typical follow-up exceeding 2 years, the app uses the 2-year estimate for smoking cessation as the basis for prospective risk reduction estimation.
  • For the purposed of this app, smokers are defined as cigarette smokers in accordance with the patient populations studied in the relevant clinical trials used to develop the tool. Clinical judgement should be exercised in the case of patient’s who use e-cigarettes and other nicotine and tobacco products.
  • Counseling and efforts aimed at smoking cessation should be considered for all current smokers.

Clinician Resources

Patient Resources

Understanding My Cardiovascular Risk

The "2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk" provides clear recommendations for estimating cardiovascular disease risk. Risk assessments are extremely useful when it comes to reducing risk for cardiovascular disease because they help determine whether a patient is at high risk for cardiovascular disease, and if so, what can be done to address any cardiovascular risk factors a patient may have. Here are the highlights of the guideline:

  • Risk assessments are used to determine the likelihood of a patient developing cardiovascular disease, heart attack or stroke in the future. In general, patients at higher risk for cardiovascular disease require more intensive treatment to help prevent the development of cardiovascular disease.

  • Risk assessments are calculated using a number of factors including age, gender, race, cholesterol and blood pressure levels, diabetes and smoking status, and the use of blood pressure-lowering medications. Typically, these factors are used to estimate a patient's risk of developing cardiovascular disease in the next 10 years. For example, someone who is young with no risk factors for cardiovascular disease would have a very low 10-year risk for developing cardiovascular disease. However, someone who is older with risk factors like diabetes and high blood pressure will have a much higher risk of developing cardiovascular disease in the next 10 years.

  • If a preventive treatment plan is unclear based on the calculation of risk outlined above, care providers should take into account other factors such as family history and level of C-reactive protein. Taking this additional information into account should help inform a treatment plan to reduce a patient's 10-year risk of developing cardiovascular disease.

  • Calculating the 10-year risk for cardiovascular disease using traditional risk factors is recommended every 4-6 years in patients 20-79 years old who are free from cardiovascular disease. However, conducting a more detailed 10-year risk assessment every 4-6 years is reasonable in adults ages 40-79 who are free of cardiovascular disease. Assessing a patient's 30-year risk of developing cardiovascular disease can also be useful for patients 20-59 years of age who are free of cardiovascular disease and are not at high short-term risk for cardiovascular disease.

  • Risk estimations vary drastically by gender and race. Patients with the same traditional risk factors for cardiovascular disease such as high blood pressure can have a different 10-year risk for cardiovascular disease as a result of their sex and race.

  • After care providers and patients work together to conduct a risk assessment, it's important that they discuss the implications of their findings. Together, patients and their care providers should weigh the risks and benefits of various treatments and lifestyle changes to help reduce the risk of developing cardiovascular disease.

Source: www.cardiosmart.org

Diet and Physical Activity Recommendations

The "2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk" provides recommendations for heart-healthy lifestyle choices based on the latest research and evidence. The guidelines focus on two important lifestyle choices--diet and physical activity--which can have a drastic impact on cardiovascular health. Here's what every patient should know about the latest recommendations for reducing cardiovascular disease risk through diet and exercise.

Diet

  • Diet is a vital tool for lowering cholesterol and blood pressure levels, which are two major risk factors for cardiovascular disease.
  • Patients with high cholesterol and high blood pressure levels should eat plenty of vegetables, fruits and whole grains and incorporate low-fat dairy products, poultry, fish, legumes, non-tropical vegetable oils and nuts into their diet. They should also limit intake of sweets, sugar-sweetened beverages and red meats.
  • There are many helpful strategies for heart-healthy eating, including the DASH diet and the USDA's Choose My Plate.
  • Patients who need to lower their cholesterol should reduce saturated and trans fat intake. Ideally, only 5-6% of daily caloric intake should come from saturated fat.
  • Patients with high blood pressure should consume no more than 2,400 mg of sodium a day, ideally reducing sodium intake to 1,500 mg a day. However, even reducing sodium intake in one's current diet by 1,000 mg each day can help lower blood pressure.
  • It's important to adapt the recommendations above, keeping in mind calorie requirements, as well as, personal and cultural food preferences. Nutrition therapy for other conditions like diabetes should also be considered. Doing so helps create healthy eating patterns that are realistic and sustainable.

Physical Activity

  • Regular physical activity helps lower cholesterol and blood pressure, reducing the risk for cardiovascular disease.
  • In general, adults should engage in aerobic physical activity 3-4 times a week with each session lasting an average of 40 minutes.
  • Moderate (brisk walking or jogging) to vigorous (running or biking) physical activity is recommended to reduce cholesterol levels.

Source: www.cardiosmart.org

Weight Management Recommendations

The "2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults" was created to reflect the latest research to outline best practices when it comes to treating obesity--a condition that affects more than one-third of American adults. These guidelines help address questions like "What's the best way to lose weight?" and "When is bariatric surgery appropriate?". Here is what every patient should know about the treatment of overweight and obesity:

  • Definition of obesity: Obesity is a medical condition in which excess body fat has accumulated to the extent that it can have an adverse effect on one's health. Obesity can be diagnosed using body mass index (BMI), a measurement of height and weight, as well as waist circumference. Obesity is categorized as having a BMI of 30 or greater. Abdominal obesity is defined as having a waist circumference greater than 40 inches for a man or 35 inches for a woman.

  • Benefits of weight loss: Obesity increases the risk for serious conditions such as cardiovascular disease, diabetes and death, but losing just a little bit of weight can result in significant health benefits. For an adult who is obese, losing just 3-5% of body weight can improve blood pressure and cholesterol levels and reduce the risk for cardiovascular disease and diabetes. Ideally, care providers recommend 5-10% weight loss for obese adults, which can produce even greater health benefits.

  • Weight loss strategies: There is no single diet or weight loss program that works best for all patients. In general, reduced caloric intake and a comprehensive lifestyle intervention involving physical activity and behavior modification tailored according to a patient's preferences and health status is most successful for sustained weight loss. Further, weight loss interventions should include frequent visits with health care providers and last more than one year for sustained weight loss.

  • Bariatric Surgery: Bariatric surgery may be a good option for severely obese patients to reduce their risk of health complications and improve overall health. However, bariatric surgery should be reserved for only the highest risk patients until more evidence is available on this issue. Present guidelines advise that weight loss surgery is only recommended for patients with extreme obesity (BMI ≥40) or in patients that have a BMI ≥35 in addition to a chronic health condition.

Source: www.cardiosmart.org

Blood Cholesterol Management Recommendations

The American College of Cardiology (ACC) and the American Heart Association (AHA) recently developed new standards for treating blood cholesterol. These recommendations are based on a thorough and careful review of the very latest, highest quality clinical trial research. They help care providers deliver the best care possible. This page provides some of the highlights from the new practice guidelines. The ultimate goal of the new cholesterol practice guidelines is to reduce a person's risk of heart attack, stroke and death. For this reason, the focus is not just on measuring and treating cholesterol, but identifying whether someone already has or is at risk for atherosclerotic cardiovascular disease (ASCVD) and could benefit from treatment.

What is ASCVD?

Heart attack and stroke are usually caused by atherosclerotic cardiovascular disease (ASCVD). ASCVD develops because of a build-up of sticky cholesterol-rich plaque. Over time, this plaque can harden and narrow the arteries.

These practice guidelines outline the most effective treatments that lower blood cholesterol in those individuals most likely to benefit. Most importantly, they were selected as the best strategies to lower cholesterol to help reduce future heart attack or stroke risk. Share this information with your health care provider so that you can ask questions and work together to decide what is right for you.

Key Points

Based on the most up-to-date and complete look at available clinical trial results:

  • Health care providers should focus on identifying those people who are most likely to have a heart attack or stroke and make sure they are given effective treatment to reduce their risk.

  • Cholesterol should be considered along with other factors known to make a heart attack or stroke more likely.

  • Knowing your risk of heart attack and stroke can help you and your health care provider decide whether you may need to take a medication—most likely a statin—to lower that risk.

  • If a medication is needed, statins are recommended as the first choice to lower heart attack and stroke risk among certain higher-risk patients based on an overwhelming amount of evidence. For those unable to take a statin, there are other cholesterol-lowering drugs; however, there is less research to support their use.

Evaluating Your Risk

Your health care provider will first want to assess your risk of ASCVD (assuming you don't already have it). This information will help determine if you are at high enough risk of a heart attack or stroke to need treatment.

To do this, your care provider will 1) review your medical history and 2) gauge your overall risk for heart attack or stroke. He/she will likely want to know:

  • whether you have had a heart attack, stroke or blockages in the arteries of your heart, neck, or legs.

  • your risk factors. In addition to your total cholesterol, LDL cholesterol, and HDL (so-called "good") cholesterol, your health care provider will consider your age, if you have diabetes, and whether you smoke and/or have high blood pressure.

  • about your lifestyle habits, other medical conditions, any previous drug treatments, and if anyone in your family has high cholesterol or suffered a heart attack or stroke at an early age.

A lipid or blood cholesterol panel will be needed as part of this evaluation. This blood test measures the amount of fatty substances (called lipids) in your blood. You may have to fast (not eat for a period of time) before having your blood drawn.

If there is any question about your risk of ASCVD, or whether you might benefit from drug therapy, your care provider may make additional assessments or order additional tests. The results of these tests can help you and your health care team decide what might be the best treatment for you. These tests may include:

  • Lifetime risk estimates —how likely you are to have a heart attack and stroke during your lifetime

  • Coronary artery calcium (CAC) score —a test that shows the presence of plaque or fatty build-up in the heart artery walls

  • High-sensitivity C-Reactive Protein (CRP) —a blood test that measures the amount of CRP, a marker of inflammation or irritation in the body; higher levels have been associated with heart attack and stroke

  • Ankle-brachial index (ABI) —the ratio of the blood pressure in the ankle compared to blood pressure in the arm, which can predict peripheral artery disease (PAD)

If you have very high levels of low-density lipoprotein (LDL or "bad") cholesterol, your care provider may want to find out if you have a genetic or familial form of hypercholesterolemia. This condition can be passed on in families.

Your Treatment Plan

Before coming up with a specific treatment plan, your care provider will talk with you about options for lowering your blood cholesterol and reducing your personal risk of atherosclerotic disease. This will likely include a discussion about heart-healthy living and whether you might benefit from a cholesterol-lowering medication.

Heart-Healthy Lifestyle

Adopting a heart-healthy lifestyle continues to be the first and best way to lower your risk of problems. Doing so can also help control or prevent other risk factors (for example: high blood pressure or diabetes). Experts suggest:

  • Eating a diet rich in vegetables, fruits, and whole grains ; this also includes low-fat dairy products, poultry, fish, legumes, and nuts; it limits intake of sweets, sugar-sweetened beverages and red meats.

  • Getting regular exercise ; check with your health care provider about how often and how much is right for you.

  • Maintaining a healthy weight .

  • Not smoking or getting help quitting .

  • Staying on top of your health , risk factors and medical appointments. For some people, lifestyle changes alone may not be enough to prevent a heart attack or stroke. In these cases, taking a statin at the right dose will most likely be necessary.

Medications

There are two types of cholesterol-lowering medications: statins and non-statins.

Statin Therapy

There is a large body of evidence that shows the use of a statin provides the greatest benefit and fewest safety issues. In particular, specific groups of patients appear to benefit most from taking moderate or high-intensity statin therapy. Based on this information, your care provider will likely recommend a statin if you have:

  • ASCVD

  • Very high LDL cholesterol (190 mg/dL or higher)

  • Type 2 diabetes and are between 40 and 75 years of age

  • Above a certain likelihood of having a heart attack or stroke in the next 10 years (7.5% or higher) and are between 40 and 75 years of age

In certain cases, your care provider may still recommend a statin even if you don't fit into one of the groups above. He/she will consider your overall health and other factors to help decide if you are at enough risk to benefit from a statin. Based on the guidelines, these may include:

  • Family history of premature heart attack or stroke

  • Your lifetime risk of ASCVD

  • LDL-cholesterol ≥160 mg/dL

  • hs-CRP ≥2 mg/L

  • Results from other special testing (CAC scoring, ABI)

If you are on a statin, your care provider will need to find the dose that is right for you.

  • People who have had a heart attack, stroke or other types of ASCVD tend to benefit the most from taking the highest amount (dose) of statin therapy if they tolerate it. This may be more appropriate than taking multiple drugs to lower cholesterol.

  • A more moderate dose of statin may be appropriate for some people with ASCVD, such as those over 75 years or those that might have problems taking the highest dose of a statin (i.e., those with prior organ transplantation).

Sometimes more than one statin needs to be tried before finding the one that works best.

If you are 75 years or older and have not already had a heart attack, stroke or other types of ASCVD, your care provider will discuss whether a statin is right for you.

Other cholesterol-lowering medications

Not all patients will be able to take the optimum dose of statin. After attention to lifestyle changes and statin therapy, non-statin drugs may be considered if you have high-risk with known ASCVD, diabetes, or very high LDL cholesterol values (≥190 mg/dL) and:

  • Have side effects from statins that prevent you from getting to the optimal dose or are not able to take a statin at all.

  • Are limited from taking an optimal dose due to other drugs that you are taking, including:

    • Transplant drug regimens to prevent rejection

    • Multiple drugs to treat HIV

    • Some antibiotics like erythromycin and clarithromycin or certain oral anti-fungal drugs

As always, it's important to talk with your health care provider about which medication is right for you.

What About Having Goals of Treatment?

Although keeping LDL-cholesterol lower with an optimal dose of statin is supported strongly by clinical trials, getting to a specific goal level is not.

Staying on Top of Your Risk

  • Take steps to lower your risk factors for heart attack, stroke and other problems —Make healthy choices (eating a healthy diet, getting exercise, maintaining a healthy weight and not smoking). Drug therapy, if needed, can help control risk factors.

  • Report side effects —Muscle aches are commonly reported and may or may not be due to the statin. If you are having problems, your care provider needs to know to help manage any side effects and possibly switch you to a different statin.

  • Take your medications as directed .

  • Get blood cholesterol and other tests that are recommended by your health care team. These can help assess whether statin therapy—and the dose—is working for you.

Questions to Ask

  • What are my risk factors for heart attack and stroke? Am I on the best prevention program to minimize this risk?

  • Is my cholesterol high enough that it might be due to a genetic condition?

  • What lifestyle changes can I make to stay healthy and prevent problems?

  • Do I need to be on a statin?

  • How do I monitor how I am doing?

  • What should I do if I develop muscle aches or weakness after starting the statin?

  • What do I do if I have other symptoms after starting the statin?

Source: www.cardiosmart.org

Groups that Benefit from Statin Therapy Infographic

Groups that benifit from Statins

Common Cardiovascular Terms Alphabetical Glossary

    For additional cardiovascular terms visit www.cardiosmart.org

    Clinician Resources

    Clinician Resources

    Understanding Cardiovascular Risk

    10-Year ASCVD Risk

    • The 10-year calculated ASCVD risk is a quantitative estimation of absolute risk based upon data from representative population samples.
    • The 10-year risk estimate for "optimal risk factors" is represented by the following specific risk factor numbers for an individual of the same age, sex and race: Total cholesterol of ≤ 170 mg/dL, HDL-cholesterol of ≥ 50 mg/dL, untreated systolic blood pressure of ≤ 110 mm Hg, no diabetes history, and not a current smoker.
    • While the risk estimate is applied to individuals, it is based on group averages.
    • Just because two individuals have the same estimated risk does not mean that they will or will not have the same event of interest.
    • Example: If the 10-year ASCVD risk estimate is 10%, this indicates that among 100 patients with the entered risk factor profile, 10 would be expected to have a heart attack or stroke in the next 10 years.

    Lifetime ASCVD Risk

    • The lifetime calculated ASCVD risk represents a quantitative estimation of absolute risk for a 50 year old man or woman with the same risk profile.
    • This estimation of risk is based on the grouping of risk factor levels into 5 strata.
      • All risk factors are optimal*
      • ≥1 risk factors are not optimal†
      • ≥1 risk factors are elevated‡
      • 1 major risk factor§
      • ≥2 major risk factors§
    • The division of lifetime risk by these 5 strata leads to thresholds in the data with large apparent changes in lifetime risk estimates.
    • Example: An individual that has all optimal risk factors except for a systolic blood pressure of 119 mm Hg has a lifetime ASCVD risk of 5%. In contrast, a similar individual that has all optimal risk factors except for a systolic blood pressure of 120 mm Hg has a lifetime ASCVD risk of 36%. This substantial difference in lifetime risk is due to the fact that they are in different stratum.

    *Optimal risk levels for lifetime risk are represented by the simultaneous presence of all of the following: Untreated total cholesterol <180 mg/dL, untreated blood pressure <120/<80 mm Hg, no diabetes history, and not a current smoker

    †Nonoptimal risk levels for lifetime risk are represented by 1 or more of the following: Untreated total cholesterol of 180 to 199 mg/dL, untreated systolic blood pressure of 120 to 139 mm Hg or diastolic blood pressure of 80 to 89 mm Hg, and no diabetes history and not a current smoker

    ‡Elevated risk levels for lifetime risk are represented by 1 or more of the following: Untreated total cholesterol of 200 to 239 mg/dL, untreated systolic blood pressure of 140 to 159 mm Hg or diastolic blood pressure of 90 to 99 mm Hg, and no diabetes history and not a current smoker

    §Major risk levels for lifetime risk are represented by any of the following: Total cholesterol ≥240 mg/dL or treated, systolic blood pressure ≥160 mm Hg or diastolic blood pressure ≥100 mm Hg or treated, or diabetes, or current smoker

    Lifestyle Recommendations

    Diet recommendations

    Diet recommendations for LDL-C lowering

    1. Consume a dietary pattern that emphasizes intake of vegetables, fruits, and whole grains; includes low-fat dairy products, poultry, fish, legumes, non-tropical vegetable oils and nuts; and limits intake of sweets, sugar-sweetened beverages, and red meats. (I A)
      • Adapt this dietary pattern to appropriate calorie requirements, personal and cultural food preferences, and nutrition therapy for other medical conditions (including diabetes mellitus).
      • Achieve this pattern by following plans such as the DASH dietary pattern, the USDA Food Pattern, or the AHA Diet.
    2. Aim for a dietary pattern that achieves 5-6% of calories from saturated fat. (I A)
    3. Reduce percent of calories from saturated fat. (I A)
    4. Reduce percent of calories from trans fat. (I A)

    Diet recommendations for blood pressure lowering

    1. Consume a dietary pattern that emphasizes intake of vegetables, fruits, and whole grains; includes low-fat dairy products, poultry, fish, legumes, non-tropical vegetable oils and nuts; and limits intake of sweets, sugar-sweetened beverages, and red meats. (I A)
      • Adapt this dietary pattern to appropriate calorie requirements, personal and cultural food preferences, and nutrition therapy for other medical conditions (including diabetes mellitus).
      • Achieve this pattern by following plans such as the DASH dietary pattern, the USDA Food Pattern, or the AHA Diet.
    2. Lower sodium intake. (I A)
    3. Consume no more than 2400 mg of sodium per day. (I B)

    Weight Management Recommendations

    Diets for weight loss

    1. Prescribe a diet to achieve reduced calorie intake for obese or overweight individuals who would benefit from weight loss, as part of a comprehensive lifestyle intervention with 1 of the following (I A):
      • 1200-1500 kcal/day for women and 1500-1800 kcal/day for men.
      • 500-750 kcal/day energy deficit.
      • Use one of the evidence-based diets that restricts certain food types (e.g., high-carbohydrate foods, low-fiber foods, or high-fat foods) in order to create an energy deficit by reduced food intake.
    2. Prescribe a calorie-restricted diet for obese or overweight individuals who would benefit from weight loss, based on the patient's preferences and health status, and preferably refer to a nutrition professional for counseling. (I A)

    Lifestyle interventions and counseling for weight loss

    1. Advise participation in a comprehensive lifestyle program that assists participants in adhering to a lower calorie diet and increasing physical activity through the use of behavioral strategies. (I A)
    2. Prescribe on site, high-intensity (i.e., ≥14 sessions in 6 months) comprehensive weight loss interventions provided in individual or group sessions by a trained interventionist. (I A)
    3. Consider prescription of electronically delivered weight loss programs (including by telephone) that includes personalized feedback from a trained interventionist, recognizing that it may result in smaller weight loss than face-to-face interventions. (IIa A)
    4. Consider some commercial-based programs that provide comprehensive lifestyle interventions, provided there is peer-reviewed published evidence of their safety and efficacy. (IIa A)
    5. Consider a very low calorie diet (<800 kcal/day) only in limited circumstances and only when provided by trained practitioners in a medical care setting where medical monitoring and high intensity lifestyle intervention can be provided. (IIa A)
    6. Advise individuals who have lost weight to participate long term (≥1 year) in a comprehensive weight loss maintenance program. (I A)
    7. Prescribe face-to-face or telephone-delivered weight loss maintenance programs that provide regular contact (> monthly) with a trained interventionist who helps participants engage in high levels of physical activity (i.e., 200-300 minutes/week), monitor body weight regularly (> weekly), and consume a reduced-calorie diet (need to lower body weight). (I A)

    Selection criteria for bariatric surgical treatment of obesity

    1. Advise adults with a BMI ≥40 kg/m2 or BMI ≥35 kg/m2 with obesity-related co-morbid conditions who are motivated to lose weight and who have not responded to behavioral treatment with or without pharmacotherapy with sufficient weight loss to achieve targeted health outcome goals that bariatric surgery may be an appropriate option to improve health and offer referral to an experienced bariatric surgeon for consultation and evaluation. (IIa A)

    Physical Activity Recommendations

    Physical activity recommendations for modifying lipids and blood pressure lowering

    1. Advise adults to engage in aerobic physical activity to reduce LDL-cholesterol, non-HDL-cholesterol, and blood pressure. (IIa A)
      • Frequency: 3-4 sessions a week
      • Intensity: Moderate to vigorous
      • Duration: 40 minutes on average

    Physical activity recommendations for secondary prevention*

    1. Aerobic exercise
      • Frequency: 3-5 days/week
      • Intensity: 50-80% of exercise capacity
      • Duration: 20-60 minutes
      • Modalities: Examples include walking, treadmill, cycling, rowing, stair climbing, and arm/leg ergometry
    2. Resistance exercise
      • Frequency: 2-3 days/week
      • Intensity: 10-15 repetitions/set to moderate fatigue
      • Duration: 1-3 sets of 8-10 upper and lower body exercises
      • Modalities: Examples include calisthenics, elastic bands, cuff/hand weights, dumbbells, free weights, wall pulleys, and weight machines
    *Balady GJ et al. Core components of cardiac rehabilitation/secondary prevention programs: 2007 update: a Scientific Statement of the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation 2007;115:2675-2682

    Tobacco Cessation Recommendations

    5 R's for patients not ready to quit

    1. Relevance—Encourage the patient to indicate why quitting is personally relevant.
    2. Risks—Ask the patient to identify potential negative consequences of tobacco use.
    3. Rewards—Ask the patient to identify potential benefits of stopping tobacco use.
    4. Roadblocks—Ask the patient to identify barriers or impediments to quitting.
    5. Repetition—The motivational intervention should be repeated every time an unmotivated patient has an interaction with a clinician. Tobacco users who have failed in previous quit attempts should be told that most people make repeated quit attempts before they are successful.

    5 A's for patients that are ready to quit

    1. Ask—Systematically identify all tobacco users at every visit.
    2. Advise—Strongly urge all smokers to quit.
    3. Assess—Identify smokers willing to make a quit attempt.
    4. Assist—Aid the patient in quitting.
    5. Arrange—Schedule follow-up contact.

    Groups that Benefit from Statin Therapy

    1. Secondary Prevention: Clinical ASCVD

    Clinical ASCVD includes acute coronary syndromes, history of MI, stable or unstable angina, coronary or other arterial revascularization, stroke, TIA, or peripheral arterial disease presumed to be of atherosclerotic origin.

    High-intensity statin therapy should be initiated or continued as first-line therapy in women and men ≤75 years of age who have clinical ASCVD, unless contraindicated. (I A)

    In individuals with clinical ASCVD in whom high-intensity statin therapy would otherwise be used, when high-intensity statin therapy is contraindicated or when characteristics predisposing to statin-associated adverse effects are present, moderate-intensity statin should be used as the second option if tolerated. (I A)

    In individuals with clinical ASCVD >75 years of age, it is reasonable to evaluate the potential for ASCVD risk-reduction benefits and for adverse effects, drug-drug interactions and to consider patient preferences, when initiating a moderate- or high-intensity statin. It is reasonable to continue statin therapy in those who are tolerating it. (IIa B)

    2. Primary Prevention: LDL-C ≥190 mg/dL

    Individuals with LDL-C ≥190 mg/dL or triglycerides ≥500 mg/dL should be evaluated for secondary causes of hyperlipidemia. (I B)

    Adults ≥21 years of age with primary LDL-C ≥190 mg/dL should be treated with high-intensity statin therapy unless contraindicated. For individuals unable to tolerate high-intensity statin therapy, use the maximum tolerated statin intensity. (I B)

    For individuals ≥21 years of age with an untreated primary LDL-C ≥190 mg/dL, it is reasonable to intensify statin therapy to achieve at least a 50% LDL-C reduction. (IIa B)

    For individuals ≥21 years of age with an untreated primary LDL-C ≥190 mg/dL, after the maximum intensity of statin therapy has been achieved, addition of a nonstatin drug may be considered to further lower LDL-C. Evaluate the potential for ASCVD risk reduction benefits, adverse effects, drug-drug interactions, and consider patient preferences. (IIb C)

    3. Primary Prevention: Diabetes and aged 40 to 75 years with LDL-C between 70 - 189 mg/dL

    Moderate-intensity statin therapy should be initiated or continued for adults 40 to 75 years of age with diabetes mellitus. (I A)

    High-intensity statin therapy is reasonable for adults 40 to 75 years of age with diabetes mellitus with a ≥7.5% estimated 10-year ASCVD risk unless contraindicated. (IIa B)

    In adults with diabetes mellitus, who are <40 or >75 years of age, it is reasonable to evaluate the potential for ASCVD benefits and for adverse effects, for drug-drug interactions, and to consider patient preferences when deciding to initiate, continue, or intensify statin therapy. (IIa C)

    4. Primary Prevention: No diabetes and estimated 10-year ASCVD risk of ≥7.5% who are between 40 to 75 years of age with LDL-C between 70 - 189 mg/dL

    The Pooled Cohort Equations should be used to estimate 10-year ASCVD risk for individuals with LDL-C 70 to 189 mg/dL without clinical ASCVD to guide initiation of statin therapy for the primary prevention of ASCVD. (I B)

    Before initiating statin therapy for the primary prevention of ASCVD in adults with LDL-C 70 - 189 mg/dL without clinical ASCVD or diabetes it is reasonable for clinicians and patients to engage in a discussion which considers the potential for ASCVD risk reduction benefits and for adverse effects, for drug-drug interactions, and patient preferences for treatment. (IIa C)

    Adults 40 to 75 years of age with LDL-C 70 to 189 mg/dL, without clinical ASCVD or diabetes and an estimated 10-year ASCVD risk ≥7.5% should be treated with moderate- to high-intensity statin therapy. (I A)

    It is reasonable to offer treatment with a moderate-intensity statin to adults 40 to 75 years of age, with LDL-C 70 to 189 mg/dL, without clinical ASCVD or diabetes and an estimated 10-year ASCVD risk of 5% to <7.5%. (IIa B)

    In adults with LDL-C <190 mg/dL who are not otherwise identified in a statin benefit group, or for whom after quantitative risk assessment a risk-based treatment decision is uncertain, additional factors may be considered to inform treatment decision making. In these individuals, statin therapy for primary prevention may be considered after evaluating the potential for ASCVD risk reduction benefits, adverse effects, drug-drug interactions, and discussion of patient preferences. (IIb C)

    Additional Factors

    These factors may include:

    Statin benefit may be less clear in other groups; additional factors may be considered to inform treatment decision making.

    1. 5 to <7.5% 10-year ASCVD risk
    2. Primary LDL-C ≥160 mg/dL or other evidence of genetic hyperlipidemias
    3. Family history of premature ASCVD
    4. High sensitivity C-reactive protein ≥2 mg/L
    5. Coronary artery calcium score ≥300 Agatston units or ≥75th percentile for age, sex, and ethnicity
    6. Ankle-brachial index <0.9
    7. Lifetime risk of ASCVD

    Blood Cholesterol Recommendation Summary

    Recommendations REC
    Click here for Definitions of Statin Intensity
    ACC/ AHA ACC/AHA COR ACC/ AHA ACC/AHA LOE
    A. Heart-healthy lifestyle habits should be encouraged for all individuals.
    B . The appropriate intensity of statin therapy should be initiated or continued:
    1. Clinical ASCVD*
    a. Age ≤75 y and no safety concerns: High-intensity statin I A
    b. Age >75 y or safety concerns: Moderate-intensity statin I A
    2. Primary prevention – Primary LDL–C ≥190 mg/dL
    a. Rule out secondary causes of hyperlipidemia
    b. Age ≥21y: High-intensity statin I B
    c. Achieve at least a 50% reduction in LDL–C IIa B
    d. LDL–C lowering nonstatin therapy may be considered to further reduce LDL–C IIb C
    3. Primary prevention – Diabetes 40-75 years of age and LDL–C 70-189 mg/dL
    a. Moderate-intensity statin I A
    b. Consider high-intensity statin when ≥7.5% 10-y ASCVD risk using the Pooled Cohort Equations† IIa B
    4. Primary prevention – No diabetes 40-75 years of age and LDL–C 70-189 mg/dL
    a. Estimate 10-y ASCVD risk using the Risk Calculator based on the Pooled Cohort Equations† in those NOT receiving a statin; estimate risk every 4-6 y I B
    b. To determine whether to initiate a statin, engage in a clinician-patient discussion of the potential for ASCVD risk reduction, adverse effects, drug-drug interactions, and patient preferences. IIa C
    c. Re-emphasize heart-healthy lifestyle habits and address other risk factors.
    i. ≥7.5% 10-y ASCVD risk: Moderate- or high-intensity statin I A
    ii. 5 to <7.5% 10-y ASCVD risk: Consider moderate-intensity statin IIa B
    iii. Other factors may be considered‡: LDL–C ≥160 mg/dL, family history of premature cardiovascular disease, hs-CRP ≥2.0 mg/L, CAC score ≥300 Agaston units, ABI <0.9 or lifetime ASCVD risk IIb C
    5. Primary prevention when LDL–C <190 mg/dL and age <40 or >75 y, or <5% 10-y ASCVD risk
    a. Statin therapy may be considered in selected individuals‡ IIb C
    6. Statin therapy is not routinely recommended for individuals with NYHA class II-IV heart failure or who are receiving maintenance hemodialysis
    C. Regularly monitor adherence to lifestyle and drug therapy with lipid and safety assessments.
    1. Assess adherence, response to therapy, and adverse effects within 4-12 wk following statin initiation or change in therapy. I A
    a. Measure a fasting lipid panel I A
    b. Do not routinely monitor ALT or CK unless symptomatic IIa C
    c. Screen and treat type 2 diabetes according to current practice guidelines. Heart-healthy lifestyle habits should be encouraged to prevent progression to diabetes I B
    d. Anticipated therapeutic response approximately ≥50% reduction in LDL–C from baseline for high-intensity statin and 30% to <50% for moderate-intensity statin IIa B
    i. Insufficient evidence for LDL–C or non-HDL-C treatment targets from RCTs
    ii. For those with unknown baseline LDL–C, an LDL–C <100 mg/dL was observed in RCTs of high-intensity statin therapy
    e. Less than anticipated therapeutic response:
    i. Reinforce improved adherence to lifestyle and drug therapy I A
    ii. Evaluate for secondary causes of hyperlipidemia if indicated I A
    iii. Increase statin intensity, or if on maximally-tolerated statin intensity, consider addition of nonstatin therapy in selected high-risk individuals§ IIb C
    f. Regularly monitor adherence to lifestyle and drug therapy every 3-12 mo once adherence has been established. Continued assessment of adherence for optimal ASCVD risk reduction and safety. I A
    D. In individuals intolerant of the recommended intensity of statin therapy, use the maximally-tolerated intensity of statin. I B
    1. If there are muscle or other symptoms, establish that they are related to the statin IIa B
    2. For specific recommendations on managing muscle symptoms (see Statin Safety Recommendations)

    * Clinical ASCVD includes acute coronary syndromes, history of MI, stable or unstable angina, coronary or other arterial revascularization, stroke, TIA, or peripheral arterial disease presumed to be of atherosclerotic origin.

    Estimated 10-year or "hard" ASCVD risk includes first occurrence of nonfatal MI, CHD death, and nonfatal and fatal stroke as used by the Risk Assessment Work Group in developing the Pooled Cohort Equations.

    These factors may include primary LDL–C ≥160 mg/dL or other evidence of genetic hyperlipidemias; family history of premature ASCVD with onset <55 years of age in a first-degree male relative or <65 years of age in a first-degree female relative; hs-CRP ≥2 mg/L; CAC score ≥300 Agatston units or ≥75 th percentile for age, sex, and ethnicity; ABI <0.9; or lifetime risk of ASCVD. Additional factors that might aid in individual risk assessment could be identified in the future.

    § High-risk individuals include those with clinical ASCVD, an untreated LDL–C ≥190 mg/dL suggesting genetic hypercholesterolemia, or diabetes.

    ABI indicates ankle-brachial index; ACC, American College of Cardiology; AHA, American Heart Association; ALT, alanine aminotransferase, a test of hepatic function; ASCVD, atherosclerotic cardiovascular disease; CAC, coronary artery calcium; CHD, coronary heart disease; CK, creatine kinase, a test of muscle injury; COR, Class of Recommendation; HDL-C, high-density lipoprotein cholesterol; hs-CRP, high-sensitivity C-reactive protein; LDL–C, low-density lipoprotein cholesterol; LOE, Level of Evidence; NHLBI, National Heart, Lung, and Blood Institute; NYHA, New York Heart Association; RCTs, randomized controlled trials; and TIA, transient ischemic attack.

    Recommendations for Initiation of Statin Therapy

    infographic on statin therapy

    This flow diagram is intended to serve as an easy reference guide summarizing recommendations for ASCVD risk assessment and treatment. Assessment of the potential for benefit and risk from statin therapy for ASCVD prevention provides the framework for clinical decision making incorporating patient preferences.

    * Percent reduction in LDL–C can be used as an indication of response and adherence to therapy, but is not in itself a treatment goal.

    The Pooled Cohort Equations can be used to estimate 10-year ASCVD risk in individuals with and without diabetes. The estimator within this application should be used to inform decision making in primary prevention patients not on a statin.

    Consider moderate-intensity statin as more appropriate in low-risk individuals.

    § For those in whom a risk assessment is uncertain, consider factors such as primary LDL–C ≥160 mg/dL or other evidence of genetic hyperlipidemias, family history of premature ASCVD with onset <55 years of age in a first-degree male relative or <65 years of age in a first-degree female relative, hs-CRP ≥2 mg/L, CAC score ≥300 Agatston units, or ≥75th percentile for age, sex, and ethnicity (for additional information, see http://www.mesa-nhlbi.org/CACReference.aspx), ABI <0.9, or lifetime risk of ASCVD. Additional factors that may aid in individual risk assessment may be identified in the future.

    || Potential ASCVD risk-reduction benefits. The absolute reduction in ASCVD events from moderate- or high-intensity statin therapy can be approximated by multiplying the estimated 10-year ASCVD risk by the anticipated relative risk reduction from the intensity of statin initiated (~30% for moderate-intensity statin or ~45% for high-intensity statin therapy). The net ASCVD risk reduction benefit is estimated from the number of potential ASCVD events prevented with a statin compared to the number of potential excess adverse events.

    Potential adverse effects. The excess risk of diabetes is the main consideration in ~0.1 excess cases per 100 individuals treated with a moderate-intensity statin for 1 year and ~0.3 excess cases per 100 individuals treated with a high-intensity statin for 1 year. In RCTs, both statin-treated and placebo-treated participants experienced the same rate of muscle symptoms. The actual rate of statin-related muscle symptoms in the clinical population is unclear. Muscle symptoms attributed to statin therapy should be evaluated (see Statin Safety Recommendations).

    ABI indicates ankle-brachial index; ASCVD, atherosclerotic cardiovascular disease; CAC, coronary artery calcium; hs-CRP, high-sensitivity C-reactive protein; LDL–C, low-density lipoprotein cholesterol; MI, myocardial infarction; RCT, randomized controlled trial.

    Intensities of Statin Therapy

    Low-Intensity

    Daily dose lowers LDL-C, on average by approximately <30%

    dose

    Moderate-Intensity

    Daily dose lowers LDL-C, on average by approximately 30% to <50%

    dose

    High-Intensity

    Daily dose lowers LDL-C, on average by approximately ≥50%

    dose

    Statins and doses that are approved by the U.S. FDA but were not tested in the RCTs reviewed are listed in parentheses

    * Evidence from 1 RCT (down-titration if unable to tolerate atorvastatin 80 mg)

    ** Initiation of or titration to simvastatin 80 mg is not recommended by the FDA due to increased risk of myopathy, including rhabdomyolysis

    Recommendations to Monitor Response to Statin Therapy

    infographic on statin therapy

    *Fasting lipid panel preferred. In a nonfasting individual, a non–HDL–C ≥ 220 mg/dL may indicate genetic hypercholesterolemia that requires further evaluation or a secondary etiology. If nonfasting triglycerides are ≥ 500 mg/dL, a fasting lipid panel is required.

    In those already on a statin, in whom baseline LDL–C is unknown, an LDL–C <100 mg/dL was observed in most individuals receiving high-intensity statin therapy in RCTs.

    Refer to Statin Safety Recommendations

    Statin Safety Recommendations

    Statin Selection

    To maximize the safety of statins, selection of the appropriate statin and dose in men and nonpregnant/nonnursing women should be based on patient characteristics, level of ASCVD risk, and potential for adverse effects.

    Moderate-intensity statin therapy should be used in individuals in whom high-intensity statin therapy would otherwise be recommended when characteristics predisposing them to statin associated adverse effects are present.

    Characteristics predisposing individuals to statin adverse effects include, but are not limited to: (I B)

    • Multiple or serious comorbidities, including impaired renal or hepatic function.
    • History of previous statin intolerance or muscle disorders.
    • Unexplained ALT elevations ≥3 times ULN.
    • Patient characteristics or concomitant use of drugs affecting statin metabolism.
    • >75 years of age.

    Additional characteristics that may modify the decision to use higher statin intensities may include, but are not limited to:

    • History of hemorrhagic stroke.
    • Asian ancestry.

    Statin Dosage

    • Decreasing the statin dose may be considered when 2 consecutive values of LDL-C levels are <40 mg/dL. (IIb C)
    • It may be harmful to initiate simvastatin at 80 mg daily or increase the dose of simvastatin to 80 mg daily. (III A)

    Creatine Kinase (CK)

    • CK should not be routinely measured in individuals receiving statin therapy. (III A)
    • Baseline measurement of CK is reasonable for individuals believed to be at increased risk for adverse muscle events based on a personal or family history of statin intolerance or muscle disease, clinical presentation, or concomitant drug therapy that might increase the risk for myopathy. (IIa C)
    • During statin therapy, it is reasonable to measure CK in individuals with muscle symptoms, including pain, tenderness, stiffness, cramping, weakness, or generalized fatigue. (II C)

    Muscle Symptoms

    It is reasonable to evaluate and treat muscle symptoms, including pain, tenderness, stiffness, cramping, weakness, or fatigue, in statin-treated patients according to the following management algorithm: (IIa B)

    • To avoid unnecessary discontinuation of statins, obtain a history of prior or current muscle symptoms to establish a baseline before initiating statin therapy.
    • If unexplained severe muscle symptoms or fatigue develop during statin therapy, promptly discontinue the statin and address the possibility of rhabdomyolysis by evaluating CK, creatinine, and a urinalysis for myoglobinuria.
    • If mild to moderate muscle symptoms develop during statin therapy:
      • Discontinue the statin until the symptoms can be evaluated.
      • Evaluate the patient for other conditions that might increase the risk for muscle symptoms (e.g., hypothyroidism, reduced renal or hepatic function, rheumatologic disorders such as polymyalgia rheumatica, steroid myopathy, vitamin D deficiency, or primary muscle diseases).
      • If muscle symptoms resolve, and if no contraindication exists, give the patient the original or a lower dose of the same statin to establish a causal relationship between the muscle symptoms and statin therapy.
      • If a causal relationship exists, discontinue the original statin. Once muscle symptoms resolve, use a low dose of a different statin.
      • Once a low dose of a statin is tolerated, gradually increase the dose as tolerated.
      • If, after 2 months without statin treatment, muscle symptoms or elevated CK levels do not resolve completely, consider other causes of muscle symptoms listed above.
      • If persistent muscle symptoms are determined to arise from a condition unrelated to statin therapy, or if the predisposing condition has been treated, resume statin therapy at the original dose.

    Hepatic Function

    • Baseline measurement of hepatic transaminase levels (ALT) should be performed before initiating statin therapy. (I B)
    • During statin therapy, it is reasonable to measure hepatic function if symptoms suggesting hepatotoxicity arise (e.g., unusual fatigue or weakness, loss of appetite, abdominal pain, dark colored urine or yellowing of the skin or sclera). (IIa C)

    Diabetes

    Individuals receiving statin therapy should be evaluated for new-onset diabetes mellitus according to the current diabetes screening guidelines. Those who develop diabetes mellitus during statin therapy should be encouraged to adhere to a heart healthy dietary pattern, engage in physical activity, achieve and maintain a healthy body weight, cease tobacco use, and continue statin therapy to reduce their risk of ASCVD events. (I B)

    Age and Drug Regimen Consideration

    For individuals taking any dose of statins, it is reasonable to use caution in individuals >75 years of age, as well as in individuals that are taking concomitant medications that alter drug metabolism, taking multiple drugs, or taking drugs for conditions that require complex medication regimens (e.g., those who have undergone solid organ transplantation or are receiving treatment for HIV). A review of the manufacturer's prescribing information may be useful before initiating any cholesterol-lowering drug. (IIa C)

    Cognitive Impairment

    For individuals presenting with a confusional state or memory impairment while on statin therapy, it may be reasonable to evaluate the patient for nonstatin causes, such as exposure to other drugs, as well as for systemic and neuropsychiatric causes, in addition to the possibility of adverse effects associated with statin drug therapy. (IIb C)

    Understanding My Cardiovascular Risk

    The "2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk" provides clear recommendations for estimating cardiovascular disease risk. Risk assessments are extremely useful when it comes to reducing risk for cardiovascular disease because they help determine whether a patient is at high risk for cardiovascular disease, and if so, what can be done to address any cardiovascular risk factors a patient may have. Here are the highlights of the guideline:

    • Risk assessments are used to determine the likelihood of a patient developing cardiovascular disease, heart attack or stroke in the future. In general, patients at higher risk for cardiovascular disease require more intensive treatment to help prevent the development of cardiovascular disease.

    • Risk assessments are calculated using a number of factors including age, gender, race, cholesterol and blood pressure levels, diabetes and smoking status, and the use of blood pressure-lowering medications. Typically, these factors are used to estimate a patient's risk of developing cardiovascular disease in the next 10 years. For example, someone who is young with no risk factors for cardiovascular disease would have a very low 10-year risk for developing cardiovascular disease. However, someone who is older with risk factors like diabetes and high blood pressure will have a much higher risk of developing cardiovascular disease in the next 10 years.

    • If a preventive treatment plan is unclear based on the calculation of risk outlined above, care providers should take into account other factors such as family history and level of C-reactive protein. Taking this additional information into account should help inform a treatment plan to reduce a patient's 10-year risk of developing cardiovascular disease.

    • Calculating the 10-year risk for cardiovascular disease using traditional risk factors is recommended every 4-6 years in patients 20-79 years old who are free from cardiovascular disease. However, conducting a more detailed 10-year risk assessment every 4-6 years is reasonable in adults ages 40-79 who are free of cardiovascular disease. Assessing a patient's 30-year risk of developing cardiovascular disease can also be useful for patients 20-59 years of age who are free of cardiovascular disease and are not at high short-term risk for cardiovascular disease.

    • Risk estimations vary drastically by gender and race. Patients with the same traditional risk factors for cardiovascular disease such as high blood pressure can have a different 10-year risk for cardiovascular disease as a result of their sex and race.

    • After care providers and patients work together to conduct a risk assessment, it's important that they discuss the implications of their findings. Together, patients and their care providers should weigh the risks and benefits of various treatments and lifestyle changes to help reduce the risk of developing cardiovascular disease.

    Source: www.cardiosmart.org

    Diet and Physical Activity Recommendations

    The "2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk" provides recommendations for heart-healthy lifestyle choices based on the latest research and evidence. The guidelines focus on two important lifestyle choices--diet and physical activity--which can have a drastic impact on cardiovascular health. Here's what every patient should know about the latest recommendations for reducing cardiovascular disease risk through diet and exercise.

    Diet

    • Diet is a vital tool for lowering cholesterol and blood pressure levels, which are two major risk factors for cardiovascular disease.
    • Patients with high cholesterol and high blood pressure levels should eat plenty of vegetables, fruits and whole grains and incorporate low-fat dairy products, poultry, fish, legumes, non-tropical vegetable oils and nuts into their diet. They should also limit intake of sweets, sugar-sweetened beverages and red meats.
    • There are many helpful strategies for heart-healthy eating, including the DASH diet and the USDA's Choose My Plate.
    • Patients who need to lower their cholesterol should reduce saturated and trans fat intake. Ideally, only 5-6% of daily caloric intake should come from saturated fat.
    • Patients with high blood pressure should consume no more than 2,400 mg of sodium a day, ideally reducing sodium intake to 1,500 mg a day. However, even reducing sodium intake in one's current diet by 1,000 mg each day can help lower blood pressure.
    • It's important to adapt the recommendations above, keeping in mind calorie requirements, as well as, personal and cultural food preferences. Nutrition therapy for other conditions like diabetes should also be considered. Doing so helps create healthy eating patterns that are realistic and sustainable.

    Physical Activity

    • Regular physical activity helps lower cholesterol and blood pressure, reducing the risk for cardiovascular disease.
    • In general, adults should engage in aerobic physical activity 3-4 times a week with each session lasting an average of 40 minutes.
    • Moderate (brisk walking or jogging) to vigorous (running or biking) physical activity is recommended to reduce cholesterol levels.

    Source: www.cardiosmart.org

    Weight Management Recommendations

    The "2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults" was created to reflect the latest research to outline best practices when it comes to treating obesity--a condition that affects more than one-third of American adults. These guidelines help address questions like "What's the best way to lose weight?" and "When is bariatric surgery appropriate?". Here is what every patient should know about the treatment of overweight and obesity:

    • Definition of obesity: Obesity is a medical condition in which excess body fat has accumulated to the extent that it can have an adverse effect on one's health. Obesity can be diagnosed using body mass index (BMI), a measurement of height and weight, as well as waist circumference. Obesity is categorized as having a BMI of 30 or greater. Abdominal obesity is defined as having a waist circumference greater than 40 inches for a man or 35 inches for a woman.

    • Benefits of weight loss: Obesity increases the risk for serious conditions such as cardiovascular disease, diabetes and death, but losing just a little bit of weight can result in significant health benefits. For an adult who is obese, losing just 3-5% of body weight can improve blood pressure and cholesterol levels and reduce the risk for cardiovascular disease and diabetes. Ideally, care providers recommend 5-10% weight loss for obese adults, which can produce even greater health benefits.

    • Weight loss strategies: There is no single diet or weight loss program that works best for all patients. In general, reduced caloric intake and a comprehensive lifestyle intervention involving physical activity and behavior modification tailored according to a patient's preferences and health status is most successful for sustained weight loss. Further, weight loss interventions should include frequent visits with health care providers and last more than one year for sustained weight loss.

    • Bariatric Surgery: Bariatric surgery may be a good option for severely obese patients to reduce their risk of health complications and improve overall health. However, bariatric surgery should be reserved for only the highest risk patients until more evidence is available on this issue. Present guidelines advise that weight loss surgery is only recommended for patients with extreme obesity (BMI ≥40) or in patients that have a BMI ≥35 in addition to a chronic health condition.

    Source: www.cardiosmart.org

    Blood Cholesterol Management Recommendations

    The American College of Cardiology (ACC) and the American Heart Association (AHA) recently developed new standards for treating blood cholesterol. These recommendations are based on a thorough and careful review of the very latest, highest quality clinical trial research. They help care providers deliver the best care possible. This page provides some of the highlights from the new practice guidelines. The ultimate goal of the new cholesterol practice guidelines is to reduce a person's risk of heart attack, stroke and death. For this reason, the focus is not just on measuring and treating cholesterol, but identifying whether someone already has or is at risk for atherosclerotic cardiovascular disease (ASCVD) and could benefit from treatment.

    What is ASCVD?

    Heart attack and stroke are usually caused by atherosclerotic cardiovascular disease (ASCVD). ASCVD develops because of a build-up of sticky cholesterol-rich plaque. Over time, this plaque can harden and narrow the arteries.

    These practice guidelines outline the most effective treatments that lower blood cholesterol in those individuals most likely to benefit. Most importantly, they were selected as the best strategies to lower cholesterol to help reduce future heart attack or stroke risk. Share this information with your health care provider so that you can ask questions and work together to decide what is right for you.

    Key Points

    Based on the most up-to-date and complete look at available clinical trial results:

    • Health care providers should focus on identifying those people who are most likely to have a heart attack or stroke and make sure they are given effective treatment to reduce their risk.

    • Cholesterol should be considered along with other factors known to make a heart attack or stroke more likely.

    • Knowing your risk of heart attack and stroke can help you and your health care provider decide whether you may need to take a medication—most likely a statin—to lower that risk.

    • If a medication is needed, statins are recommended as the first choice to lower heart attack and stroke risk among certain higher-risk patients based on an overwhelming amount of evidence. For those unable to take a statin, there are other cholesterol-lowering drugs; however, there is less research to support their use.

    Evaluating Your Risk

    Your health care provider will first want to assess your risk of ASCVD (assuming you don't already have it). This information will help determine if you are at high enough risk of a heart attack or stroke to need treatment.

    To do this, your care provider will 1) review your medical history and 2) gauge your overall risk for heart attack or stroke. He/she will likely want to know:

    • whether you have had a heart attack, stroke or blockages in the arteries of your heart, neck, or legs.

    • your risk factors. In addition to your total cholesterol, LDL cholesterol, and HDL (so-called "good") cholesterol, your health care provider will consider your age, if you have diabetes, and whether you smoke and/or have high blood pressure.

    • about your lifestyle habits, other medical conditions, any previous drug treatments, and if anyone in your family has high cholesterol or suffered a heart attack or stroke at an early age.

    A lipid or blood cholesterol panel will be needed as part of this evaluation. This blood test measures the amount of fatty substances (called lipids) in your blood. You may have to fast (not eat for a period of time) before having your blood drawn.

    If there is any question about your risk of ASCVD, or whether you might benefit from drug therapy, your care provider may make additional assessments or order additional tests. The results of these tests can help you and your health care team decide what might be the best treatment for you. These tests may include:

    • Lifetime risk estimates —how likely you are to have a heart attack and stroke during your lifetime

    • Coronary artery calcium (CAC) score —a test that shows the presence of plaque or fatty build-up in the heart artery walls

    • High-sensitivity C-Reactive Protein (CRP) —a blood test that measures the amount of CRP, a marker of inflammation or irritation in the body; higher levels have been associated with heart attack and stroke

    • Ankle-brachial index (ABI) —the ratio of the blood pressure in the ankle compared to blood pressure in the arm, which can predict peripheral artery disease (PAD)

    If you have very high levels of low-density lipoprotein (LDL or "bad") cholesterol, your care provider may want to find out if you have a genetic or familial form of hypercholesterolemia. This condition can be passed on in families.

    Your Treatment Plan

    Before coming up with a specific treatment plan, your care provider will talk with you about options for lowering your blood cholesterol and reducing your personal risk of atherosclerotic disease. This will likely include a discussion about heart-healthy living and whether you might benefit from a cholesterol-lowering medication.

    Heart-Healthy Lifestyle

    Adopting a heart-healthy lifestyle continues to be the first and best way to lower your risk of problems. Doing so can also help control or prevent other risk factors (for example: high blood pressure or diabetes). Experts suggest:

    • Eating a diet rich in vegetables, fruits, and whole grains ; this also includes low-fat dairy products, poultry, fish, legumes, and nuts; it limits intake of sweets, sugar-sweetened beverages and red meats.

    • Getting regular exercise ; check with your health care provider about how often and how much is right for you.

    • Maintaining a healthy weight .

    • Not smoking or getting help quitting .

    • Staying on top of your health , risk factors and medical appointments. For some people, lifestyle changes alone may not be enough to prevent a heart attack or stroke. In these cases, taking a statin at the right dose will most likely be necessary.

    Medications

    There are two types of cholesterol-lowering medications: statins and non-statins.

    Statin Therapy

    There is a large body of evidence that shows the use of a statin provides the greatest benefit and fewest safety issues. In particular, specific groups of patients appear to benefit most from taking moderate or high-intensity statin therapy. Based on this information, your care provider will likely recommend a statin if you have:

    • ASCVD

    • Very high LDL cholesterol (190 mg/dL or higher)

    • Type 2 diabetes and are between 40 and 75 years of age

    • Above a certain likelihood of having a heart attack or stroke in the next 10 years (7.5% or higher) and are between 40 and 75 years of age

    In certain cases, your care provider may still recommend a statin even if you don't fit into one of the groups above. He/she will consider your overall health and other factors to help decide if you are at enough risk to benefit from a statin. Based on the guidelines, these may include:

    • Family history of premature heart attack or stroke

    • Your lifetime risk of ASCVD

    • LDL-cholesterol ≥160 mg/dL

    • hs-CRP ≥2 mg/L

    • Results from other special testing (CAC scoring, ABI)

    If you are on a statin, your care provider will need to find the dose that is right for you.

    • People who have had a heart attack, stroke or other types of ASCVD tend to benefit the most from taking the highest amount (dose) of statin therapy if they tolerate it. This may be more appropriate than taking multiple drugs to lower cholesterol.

    • A more moderate dose of statin may be appropriate for some people with ASCVD, such as those over 75 years or those that might have problems taking the highest dose of a statin (i.e., those with prior organ transplantation).

    Sometimes more than one statin needs to be tried before finding the one that works best.

    If you are 75 years or older and have not already had a heart attack, stroke or other types of ASCVD, your care provider will discuss whether a statin is right for you.

    Other cholesterol-lowering medications

    Not all patients will be able to take the optimum dose of statin. After attention to lifestyle changes and statin therapy, non-statin drugs may be considered if you have high-risk with known ASCVD, diabetes, or very high LDL cholesterol values (≥190 mg/dL) and:

    • Have side effects from statins that prevent you from getting to the optimal dose or are not able to take a statin at all.

    • Are limited from taking an optimal dose due to other drugs that you are taking, including:

      • Transplant drug regimens to prevent rejection

      • Multiple drugs to treat HIV

      • Some antibiotics like erythromycin and clarithromycin or certain oral anti-fungal drugs

    As always, it's important to talk with your health care provider about which medication is right for you.

    What About Having Goals of Treatment?

    Although keeping LDL-cholesterol lower with an optimal dose of statin is supported strongly by clinical trials, getting to a specific goal level is not.

    Staying on Top of Your Risk

    • Take steps to lower your risk factors for heart attack, stroke and other problems —Make healthy choices (eating a healthy diet, getting exercise, maintaining a healthy weight and not smoking). Drug therapy, if needed, can help control risk factors.

    • Report side effects —Muscle aches are commonly reported and may or may not be due to the statin. If you are having problems, your care provider needs to know to help manage any side effects and possibly switch you to a different statin.

    • Take your medications as directed .

    • Get blood cholesterol and other tests that are recommended by your health care team. These can help assess whether statin therapy—and the dose—is working for you.

    Questions to Ask

    • What are my risk factors for heart attack and stroke? Am I on the best prevention program to minimize this risk?

    • Is my cholesterol high enough that it might be due to a genetic condition?

    • What lifestyle changes can I make to stay healthy and prevent problems?

    • Do I need to be on a statin?

    • How do I monitor how I am doing?

    • What should I do if I develop muscle aches or weakness after starting the statin?

    • What do I do if I have other symptoms after starting the statin?

    Source: www.cardiosmart.org

    Groups that Benefit from Statin Therapy Infographic

    Groups that benifit from Statins

    Common Cardiovascular Terms Alphabetical Glossary

      For additional cardiovascular terms visit www.cardiosmart.org

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