LDL-C
Reduction
ACC suggests
Current LDL-C
(mmol/L)
Current LDL-C
(mg/dL)
ACC suggests   
ACC suggests   
Non HDL-C
(mmol/L)
Non HDL-C
(mg/dL)
~
ACC suggests   
ACC suggests   

Evaluate

This app assumes that the patient is currently taking the maximally tolerated dose of statin therapy or has attempted to take statin therapy

Enter Patient Profile

Select Prevention Group

Select Patient

Baseline LDL-C (before statin initiation)

See resources for more information on what constitutes very high-risk

What is patient's 10-year ASCVD risk? Calculate 10-year risk score

CALCULATED RISK SCORE:  %

Are there diabetes-specific risk enhancers or evidence of subclinical atherosclerosis?

Is there other existing documentation of, or incidental finding of, significant burden of subclinical atherosclerosis?

Enter Patient Details

mg/dL
LDL-C has increased from baseline Value must be entered in format xxx.xxx Value must be entered in format xxx.xxx Value must be between 1.036 - 25.874 (mmol/L) Value must be entered in format xxx.xxx Data message
edit in lipid panel
mg/dL
Value must be entered in format xxx.xxx Value must be entered in format xxx.xxx Value must be between 1.036 - 25.874 (mmol/L) Value must be entered in format xxx.xxx Data message
mg
mg/dL
Value must be entered in format xxx.xxx Value must be entered in format xxx.xxx Value must be between 1.036 - 4.920 (mmol/L) Value must be between 40 - 189 (mg/dL) Value must be between 1.813 - 4.920 (mmol/L) Value must be between 70 - 189 (mg/dL) Value must be greater than or equal to 4.921 (mmol/L) Value must be greater than or equal to 190 (mg/dL) Data message

Response To LDL-C Therapy

Patient's Actual ACC Suggested
Main Consideration
% LDL-C Reduction from pretreatment
30-49%
Additional Consideration
Current LDL-C ()
Non HDL-C () ~
Statin Intensity ~
View list of markers to consider
  • Continue to monitor adherence to medications and lifestyle, and LDL-C response to therapy.
  • If persistent hypertriglyceridemia , refer to the ACC Hypertriglyceridemia application.
  • Emphasize lifestyle to reduce ASCVD risk.
  • If risk enhancers present, risk discussion regarding moderate intensity statin therapy.
  • If risk enhancers present, risk discussion regarding moderate intensity statin therapy.
  • If risk enhancers present, risk discussion regarding moderate intensity statin therapy.
  • If risk enhancers present, risk discussion regarding moderate-intensity statin therapy.
  • Consider deferring statin therapy and remeasuring CAC in 3-5 years unless diabetes, LDL-C ≥ 190 mg/dL, family history of premature CHD, or cigarette smoking are present. If any high-risk condition is present, recommend statin therapy.
  • If risk estimate + risk enhancers favor statin therapy, initiate statin therapy to reduce LDL-C ≥ 30-49%.
  • If risk estimate + risk enhancers favor statin therapy, initiate statin therapy to reduce LDL-C ≥ 30-49%.
  • Consider deferring statin therapy and remeasuring CAC in 3-5 years unless diabetes, LDL-C ≥ 190 mg/dL, family history of premature CHD, or cigarette smoking are present. If any high-risk condition is present, recommend statin therapy.

Calculate Patient Group

This tool is meant for patients who have attempted statin therapy, and cannot provide accurate advice for pretreatment patients.
No advice for this scenario.

Considerations for Lowering LDL-C

Considerations for Lowering LDL-C

  • It is recommended that for adults aged 20-39 years with long duration of diabetes, albuminuria, eGFR <60 ml/min/1.73 m2, retinopathy, neuropathy, or ABI <0.9, it may be reasonable to initiate statin therapy.
  • Once acceptable response is achieved with lipid-lowering therapy, continue to monitor adherence to lifestyle modifications, medications, and LDL-C response to therapy. If persistent hypertriglyceridemia , refer to the ACC Hypertriglyceridemia application.

Considerations for Lowering LDL-C

Considerations for Lowering LDL-C

  • It is reasonable to continue moderate- or high-intensity statin therapy in patients with diabetes after age 75 years if therapy is well-tolerated.
  • It may be reasonable to have a clinician patient discussion in which the potential benefits and risks of initiating statin therapy in this age group are reviewed. The decision to initiate nonstatin therapy in individuals >75 years of age should be individualized based on considerations of expected longevity, frailty, polypharmacy, susceptibility to adverse effects of treatment, and goals of care.
  • Once acceptable response is achieved with lipid-lowering therapy, continue to monitor adherence to lifestyle modifications, medications, and LDL-C response to therapy. If persistent hypertriglyceridemia , refer to the ACC Hypertriglyceridemia application.

Considerations for Lowering LDL-C

  • Patients aged <40 years without ASCVD but with ASCVD risk factors should not be considered for 10-year risk assessment
  • Adults <40 years of age with LDL-C values ≥160 mg/dL and/or a family history of premature cardiovascular disease may benefit from statin consideration.
  • In patients with a family history of premature ASCVD, measurement of lipoprotein a (Lp(a)) may help identify patients who may benefit from early statin initiation due to the high heritability of Lp(a) and its well-known association with higher ASCVD risk. For patients >32 years of age, CAC scoring has been shown to help identify those patients with traditional risk factor burden or a family history of premature cardiovascular disease. These patients may be at higher long-term absolute risks for cardiovascular disease and therefore may be more likely to experience potential benefit from statin initiation in early adult life.
  • Continue to monitor adherence to lifestyle modifications, medications, and LDL-C response to therapy. If persistent hypertriglyceridemia , refer to the ACC Hypertriglyceridemia application.

Considerations for Lowering LDL-C

Considerations for Lowering LDL-C

  • Increase to a high intensity statin if not already taking.
  • Once acceptable response is achieved with lipid-lowering therapy, continue to monitor adherence to lifestyle modifications, medications, and LDL-C response to therapy. If persistent hypertriglyceridemia , refer to the ACC Hypertriglyceridemia application.

Considerations for Lowering LDL-C

  • Increase to a high intensity statin if not already taking.
  • Once acceptable response is achieved with lipid-lowering therapy, continue to monitor adherence to lifestyle modifications, medications, and LDL-C response to therapy. If persistent hypertriglyceridemia , refer to the ACC Hypertriglyceridemia application.

Considerations for Lowering LDL-C

  • Increase to a high intensity statin if not already taking.
  • Once acceptable response is achieved with lipid-lowering therapy, continue to monitor adherence to lifestyle modifications, medications, and LDL-C response to therapy. If persistent hypertriglyceridemia , refer to the ACC Hypertriglyceridemia application.

Considerations for Lowering LDL-C

Considerations for Lowering LDL-C

Considerations for Lowering LDL-C

Considerations for Lowering LDL-C

Considerations for Lowering LDL-C

Considerations for Lowering LDL-C

  • In primary prevention patients >75 years of age, the patient clinician discussion should consider the limited adequate RCT data to inform these decisions. The writing committee recommends consideration of ASCVD risk in the context of patient goals, competing risks for non-cardiovascular disease death, patient frailty, susceptibility to adverse effects, and polypharmacy to derive individual-level recommendations for statin initiation in this highly heterogenous groups.
  • When the goals of therapy in the clinician patient discussion have been achieved, it is reasonable to continue to monitor adherence to lifestyle modifications, medication, and LDL-C response to therapy. If there is persistent hypertriglyceridemia , clinicians should refer to the ACC Hypertriglyceridemia application.

Considerations for Lowering LDL-C

Considerations for Lowering LDL-C

Considerations for Lowering LDL-C

Considerations for Lowering LDL-C

Additional Considerations for Lowering LDL-C

Optimizing Lifestyle and Medication Therapy

Addressing adherence
  • Assess the number of missed statin doses per month.
  • Evaluate barriers to adherence. See patient tools in the Reference Section of this app for help.
Addressing lifestyle
  • Diet
  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.
    1. Adapt this dietary pattern to appropriate calorie requirements, personal and cultural food preferences, and nutrition therapy for other medical conditions (including diabetes).
    2. 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.
  3. Reduce percent of calories from saturated fat.
  4. Reduce percent of calories from trans fat.
  • Exercise
  • In general, advise adults to engage in aerobic physical activity to reduce LDL-C and non–HDL-C: 3–4 sessions per week, lasting on average 40 min per session, and involving moderate- to vigorous-intensity physical activity.

  • Supplementation
  • May consider incorporation of soluble dietary fiber and phytosterols

  •  
  • See Resource section of this app for more information.
Evaluating for statin intolerance
Routine clinical assessment and interventions
  • Major ASCVD risk factors, including tobacco use, diabetes, elevated blood pressure, and obesity should be addressed as needed and controlled.
Consider specialists
  • Consider referral to lipid specialist and registered dietician nutritionist for all patients.
  • May consider evinacumab lomitapide or LDL apheresis for appropriate patients.
Addressing adherence
  • Assess the number of missed statin doses per month.
  • Evaluate barriers to adherence. See patient tools in the Reference Section of this app for help.
Addressing lifestyle
  • Diet
  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.
    1. Adapt this dietary pattern to appropriate calorie requirements, personal and cultural food preferences, and nutrition therapy for other medical conditions (including diabetes).
    2. 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.
  3. Reduce percent of calories from saturated fat.
  4. Reduce percent of calories from trans fat.
  • Exercise
  • In general, advise adults to engage in aerobic physical activity to reduce LDL-C and non–HDL-C: 3–4 sessions per week, lasting on average 40 min per session, and involving moderate- to vigorous-intensity physical activity.

  • Supplementation
  • May consider incorporation of soluble dietary fiber and phytosterols.

  •  
  • See Resource section of this app for more information.
Evaluating for statin intolerance
  • Evaluate for statin intolerance if unable to tolerate a moderate intensity statin . See ACC's Statin Intolerance App for help.
  • If intolerant of at least 2 statin therapies with 1 attempt at lowest approved FDA daily dose and trial of alternative statin therapy dosing regimens, consider first-line therapy with ezetimibe and/or PCSK9 mAb, second-line therapy with bempedoic acid or inclisiran, and third-line therapy with evinacumab for HoFH.
Routine clinical assessment and interventions
  • Major ASCVD risk factors, including tobacco use, diabetes, elevated blood pressure, and obesity should be addressed as needed and controlled.
Consider specialists
  • Consider referral to lipid specialist and registered dietician nutritionist for all patients.
  • May consider evinacumab, lomitapide, or LDL apheresis for appropriate patients.
Addressing adherence
  • Assess the number of missed statin doses per month.
  • Evaluate barriers to adherence. See patient tools in the Reference Section of this app for help.
Addressing lifestyle
  • Diet
  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.
    1. Adapt this dietary pattern to appropriate calorie requirements, personal and cultural food preferences, and nutrition therapy for other medical conditions (including diabetes).
    2. 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.
  3. Reduce percent of calories from saturated fat.
  4. Reduce percent of calories from trans fat.
  • Exercise
  • In general, advise adults to engage in aerobic physical activity to reduce LDL-C and non–HDL-C: 3–4 sessions per week, lasting on average 40 min per session, and involving moderate- to vigorous-intensity physical activity.

  • Supplementation
  • May consider incorporation of soluble dietary fiber and phytosterols.

  •  
  • See Resource section of this app for more information.
Evaluating for statin intolerance
  • Evaluate for statin intolerance if unable to tolerate a moderate intensity statin . See ACC's Statin Intolerance App for help.
  • If intolerant of at least 2 statin therapies with 1 attempt at lowest approved FDA daily dose and trial of alternative statin therapy dosing regimens, consider ezetimibe first line; BAS second line; consider bempedoic acid as third line.
Routine clinical assessment and interventions
  • Major ASCVD risk factors, including tobacco use, diabetes, elevated blood pressure, and obesity should be addressed as needed and controlled.
Consider specialists
  • Consider referral to lipid specialist and registered dietician nutritionist for all patients.
  • May consider evinacumab, lomitapide, or LDL apheresis for appropriate patients.

Patient-Clinician Discussion Points for Adding Non-Statin Therapy

Potential for additional ASCVD risk reduction from addition of nonstatin therapy to evidence-based statin therapy to lower LDL-C
  • Percentage LDL-C reduction achieved with evidence-based statin therapy (if <50% and not on maximally tolerated statin, should increase statin therapy first and reinforce lifestyle modifications) and whether patient is above LDL-C threshold for consideration of nonstatin therapies
  • For patients with ASCVD, patient’s status as very high risk or not very high risk on evidence-based statin therapy (See Criteria for Defining Patients at Very High-Risk of future ASCVD Events)
  • For patients without ASCVD or baseline LDL-C ≥190 mg/dL, patient’s baseline predicted 10-year ASCVD risk pre-statin and presence of risk enhancing factors (See Risk-Enhancing Factors for Clinician-Patient Risk Discussion)
  • Available scientific evidence of ASCVD risk reduction (and magnitude of benefit) when nonstatin therapy is added to evidence-based statin therapy
  • Additional desired % LDL-C lowering beyond that achieved on evidence-based statin therapy
  • Mean percentage LDL-C lowering expected with proposed nonstatin therapy when added to evidence-based statin therapy
Potential for clinically significant adverse events or drug-drug interactions from addition of nonstatin therapy to evidence-based statin therapy for lowering LDL-C
Patient preferences and considerations
  • Potential out-of-pocket cost of therapy to the patient (e.g., insurance plan coverage, pharmacy or medical benefit, copayment, availability of assistance programs)
  • Patient’s perception of benefit from addition of nonstatin therapy
  • Convenience of nonstatin therapy (e.g., route, setting [home or medical office], frequency of administration, pill burden, storage)
  • Potential of nonstatin therapy to jeopardize adherence to other evidence-based therapies
  • Anticipated life expectancy, comorbidities, and impact of therapy on quality of life
Once acceptable response is achieved with lipid-lowering therapy, continue to monitor LDL-C level and adherence to medications and lifestyle. If persistent hypertriglyceridemia see ACC’s Hypertriglyceridemia App for help.

Comorbidities

  • Diabetes mellitus
  • recent (<3 months) ASCVD event
  • ASCVD event while already taking a statin
  • poorly controlled other major ASCVD risk factors
  • elevated Lp(a)
  • CKD
  • symptomatic heart failure
  • maintenance hemodialysis
  • baseline LDL-C ≥190 mg/dL not due to secondary causes
  • age ≥ 65 years
  • prior MI or non-hemorrhagic stroke
  • current daily cigarette smoking
  • symptomatic PAD with prior history of MI or stroke
  • history of non-MI related coronary revascularization
  • residual coronary artery disease with ≥ 40% stenosis in ≥ 2 large vessels
  • HDL-C <40 mg/dL for men and <50 mg/dL for women
  • hs-CRP >2 mg/L
  • or metabolic syndrome

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