Recommendations for Adults With High Blood Cholesterol

Referenced studies that support recommendations are summarized in Online Data Supplements 11 and 12.

COR	LOE	RECOMMENDATIONS
I	A	1. In adults at intermediate risk (≥7.5% to <20% 10-year ASCVD risk), statin therapy reduces risk of ASCVD, and in the context of a risk discussion, if a decision is made for statin therapy, a moderate-intensity statin should be recommended (S4.3-2–S4.3-9). Adapted from recommendations in the 2018 Cholesterol Clinical Practice Guidelines (S4.3-1).
I	A	2. In intermediate risk (≥7.5% to <20% 10-year ASCVD risk) patients, LDL-C levels should be reduced by 30% or more, and for optimal ASCVD risk reduction, especially in patients at high risk (≥20% 10-year ASCVD risk), levels should be reduced by 50% or more (S4.3-2,S4.3-5–S4.3-10). Adapted from recommendations in the 2018 Cholesterol Clinical Practice Guidelines (S4.3-1).
I	A	3. In adults 40 to 75 years of age with diabetes, regardless of estimated 10-year ASCVD risk, moderate-intensity statin therapy is indicated (S4.3-11–S4.3-19). Included from recommendations in the 2018 Cholesterol Clinical Practice Guidelines (S4.3-1). Included from recommendations in the 2018 Cholesterol Clinical Practice Guidelines (S4.3-1).
I	B-R	4. In patients 20 to 75 years of age with an LDL-C level of 190 mg/dL (≥4.9 mmol/L) or higher, maximally tolerated statin therapy is recommended (S4.3-2,S4.3-20–S4.3-25). Included from recommendations in the 2018 Cholesterol Clinical Practice Guidelines (S4.3-1).
IIa	B-R	5. In adults with diabetes mellitus who have multiple ASCVD risk factors, it is reasonable to prescribe high-intensity statin therapy with the aim to reduce LDL-C levels by 50% or more (S4.3-2,S4.3-7). Included from recommendations in the 2018 Cholesterol Clinical Practice Guidelines (S4.3-1).
IIa	B-R	6. In intermediate-risk (≥7.5% to <20% 10-year ASCVD risk) adults, risk-enhancing factors favor initiation or intensification of statin therapy (S4.3-7,S4.3-26–S4.3-33). Adapted from recommendations in the 2018 Cholesterol Clinical Practice Guidelines (S4.3-1).
IIa	B-NR	7. In intermediate-risk (≥7.5% to <20% 10-year ASCVD risk) adults or selected borderline-risk (5% to <7.5% 10-year ASCVD risk) adults in whom a coronary artery calcium score is measured for the purpose of making a treatment decision, AND If the coronary artery calcium score is zero, it is reasonable to withhold statin therapy and reassess in 5 to 10 years, as long as higher-risk conditions are absent (e.g., diabetes, family history of premature CHD, cigarette smoking); If coronary artery calcium score is 1 to 99, it is reasonable to initiate statin therapy for patients ≥55 years of age; If coronary artery calcium score is 100 or higher or in the 75th percentile or higher, it is reasonable to initiate statin therapy (S4.3-28,S4.3-34). Adapted from recommendations in the 2018 Cholesterol Clinical Practice Guidelines (S4.3-1).
IIb	B-R	8. In patients at borderline risk (5% to <7.5% 10-year ASCVD risk), in risk discussion, the presence of risk-enhancing factors may justify initiation of moderate-intensity statin therapy (S4.3-28,S4.3-35). Adapted from recommendations in the 2018 Cholesterol Clinical Practice Guidelines (S4.3-1).