Hyperlipidemia

First determine whether the patient has established ASCVD. In secondary prevention, high-intensity statin therapy is recommended; this group should not be managed as risk-calculator primary prevention. Annals of Internal MedicineAnnals of Internal MedicineDyslipidemia | Annals of Internal Medicine - ACP Journals

For adults without known ASCVD, separate severe hypercholesterolemia (LDL-C at least 190 mg/dL) from risk-based primary prevention. The ACC/AHA framework cited in HIV guidance identifies LDL-C at least 190 mg/dL in adults aged 20 to 75 years as an indication for statin-based primary prevention, independent of calculated 10-year risk. clinicalinfo hivclinicalinfo hiv[PDF] Statin Therapy in People with HIV

For adults aged 40 to 75 years without ASCVD and without severe LDL-C elevation, estimate 10-year cardiovascular risk and identify dyslipidemia, diabetes, hypertension, or smoking. USPSTF recommends prescribing a statin when at least one such risk factor is present and estimated 10-year CVD risk is at least 10%; at 7.5% to less than 10%, offer a statin selectively because expected benefit is smaller. ACCACCUSPSTF Releases Updated Statin Guidelines For Primary Prevention of CVD - American College of Cardiology

Evidence is insufficient to determine the overall balance of benefits and harms for initiating statins for primary prevention after age 75 years; make this a patient-specific decision rather than automatically extending the 40-to-75-year threshold. ACCACCUSPSTF Releases Updated Statin Guidelines For Primary Prevention of CVD - American College of Cardiology

When a primary-prevention statin decision remains uncertain, coronary artery calcium can reclassify risk. A CAC score of 0 may support downgrading risk and deferring statin therapy, but do not use zero CAC as a reason to defer therapy in patients who smoke, have diabetes, poorly controlled hypertension, genetic dyslipidemia such as familial hypercholesterolemia or elevated lipoprotein(a), or a strong family history of premature ASCVD. ScienceDirectScienceDirectComparison of Transatlantic Approaches to Lipid Management: The AHA/ACC/Multisociety Guidelines vs the ESC/EAS Guidelines - ScienceDirect

For CAC 1 to 99, ACC/AHA guidance supports statin initiation in patients aged 55 years or older. A nonzero CAC result therefore shifts a previously equivocal conversation toward pharmacotherapy, particularly in this age group. ScienceDirectScienceDirectComparison of Transatlantic Approaches to Lipid Management: The AHA/ACC/Multisociety Guidelines vs the ESC/EAS Guidelines - ScienceDirect

Familial hypercholesterolemia is an autosomal dominant disorder of LDL metabolism affecting approximately 1 in 200 to 300 individuals. In a patient with severe LDL-C elevation, obtain family and medical history and perform physical examination as part of case identification; these elements, together with lipid measurements, are central to recognizing affected patients. PubMedPubMedFamilial Hypercholesterolemia - Endotext - NCBI Bookshelf

Once familial hypercholesterolemia is suspected or established, pursue cascade screening of relatives. This converts an individual lipid result into a preventive intervention for first-degree and extended family members at risk of the same inherited disorder. PubMedPubMedFamilial Hypercholesterolemia - Endotext - NCBI Bookshelf

Lifestyle measures remain appropriate but often do not achieve LDL reduction goals in familial hypercholesterolemia, so do not delay pharmacologic LDL lowering while relying on lifestyle change alone. PubMedPubMedFamilial Hypercholesterolemia - Endotext - NCBI Bookshelf

Statins are first-line lipid-lowering therapy because they have LDL-C-lowering efficacy, event-reduction evidence, and favorable cost-effectiveness across primary and secondary prevention. Before labeling a patient statin intolerant, determine whether any statin regimen is tolerated, because nonstatin therapy is generally used in addition to maximally tolerated statin therapy or when intolerance prevents adequate statin use. ScienceDirectScienceDirectPCSK9 inhibitor, ezetimibe, and bempedoic acid: Evidence-based therapies for statin-intolerant patients - ScienceDirect

Ezetimibe, PCSK9 inhibitors, and bempedoic acid each lower LDL-C and have evidence supporting reduction in major adverse cardiovascular events in high-risk or statin-intolerant populations. Their use is most clinically relevant when ASCVD risk is high and LDL-C remains inadequately controlled with a tolerated statin regimen, or when statin adverse effects preclude an adequate regimen. ScienceDirectScienceDirectPCSK9 inhibitor, ezetimibe, and bempedoic acid: Evidence-based therapies for statin-intolerant patients - ScienceDirect

Bempedoic acid is FDA-approved as an adjunct to maximally tolerated statin therapy for LDL-C lowering in patients with ASCVD or heterozygous familial hypercholesterolemia. The bempedoic acid-ezetimibe combination is also FDA-approved as an adjunct to diet and statin therapy for adults with ASCVD or heterozygous familial hypercholesterolemia who require additional LDL-C reduction. PubMedPubMedBempedoic Acid - StatPearls - NCBI Bookshelf

For patients with diabetes who are statin intolerant, the cited 2024 ADA guidance recommends bempedoic acid as an alternative LDL-lowering strategy to reduce cardiovascular events. PubMedPubMedBempedoic Acid - StatPearls - NCBI Bookshelf

For people with HIV aged 40 to 75 years, use ACC/AHA/Multisociety dyslipidemia guidance for statin-based primary prevention. For those younger than 40 years, there is no HIV-specific ACC/AHA recommendation; use shared decision-making informed by HIV-related risk factors and ACC/AHA risk enhancers. clinicalinfo hivclinicalinfo hivUpdate on Statin Therapy as Primary Prevention of Atherosclerotic Cardiovascular Disease in People With HIV | NIH

For a patient with HIV whose calculated risk creates uncertainty, explicitly incorporate HIV-related factors and conventional risk enhancers into the treatment discussion rather than treating a low calculated estimate as a categorical reason against statin therapy. clinicalinfo hivclinicalinfo hivUpdate on Statin Therapy as Primary Prevention of Atherosclerotic Cardiovascular Disease in People With HIV | NIH