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).
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).