ASCVD Risk Management Guidelines
The foundation of ASCVD risk management is promoting healthy lifestyle throughout life, followed by risk stratification using 10-year ASCVD risk estimation for adults aged 40-75 years, with statin therapy as first-line pharmacologic treatment for those at sufficient risk. 1
Risk Assessment Framework
Who Requires Risk Calculation
- Adults aged 40-75 years being evaluated for cardiovascular disease prevention should undergo 10-year ASCVD risk estimation before starting pharmacologic therapy 1
- Do not calculate risk in patients with clinical ASCVD or LDL-C ≥190 mg/dL—these patients automatically qualify for treatment 1
- Reassess risk every 4-6 years in those not receiving statin therapy 1
Risk Categories and Thresholds
- Low risk: <5% 10-year ASCVD risk 1
- Borderline risk: 5% to <7.5% 10-year ASCVD risk 1
- Intermediate risk: ≥7.5% to <20% 10-year ASCVD risk 1
- High risk: ≥20% 10-year ASCVD risk 1
Four Major Statin Benefit Groups
1. Secondary Prevention (Clinical ASCVD)
- Age ≤75 years: High-intensity statin (atorvastatin 40-80 mg or rosuvastatin 20-40 mg) 1, 2
- Age >75 years or safety concerns: Moderate-intensity statin 1
- Target ≥50% LDL-C reduction with high-intensity therapy 2
2. Primary Hypercholesterolemia (LDL-C ≥190 mg/dL)
- High-intensity statin for all patients aged ≥21 years 1, 2
- Rule out secondary causes of hyperlipidemia first 1
- Achieve at least 50% LDL-C reduction 1
- Consider adding non-statin therapy if LDL-C remains elevated 1
3. Diabetes Mellitus (Ages 40-75 Years, LDL-C 70-189 mg/dL)
- Moderate-intensity statin for all patients with diabetes in this age range 1, 2
- Consider high-intensity statin when 10-year ASCVD risk ≥7.5% 1
- Target 30-50% LDL-C reduction with moderate-intensity or ≥50% with high-intensity 2
4. Primary Prevention Without Diabetes (Ages 40-75 Years, LDL-C 70-189 mg/dL)
- ≥7.5% 10-year ASCVD risk: Moderate- to high-intensity statin after clinician-patient risk discussion 1, 2
- 5% to <7.5% 10-year ASCVD risk: Consider moderate-intensity statin if risk-enhancing factors present 1
- <5% 10-year ASCVD risk: Lifestyle modification only 1
Risk-Enhancing Factors for Borderline/Intermediate Risk
When risk-based decisions are uncertain, consider these factors 1, 2:
- Family history of premature ASCVD (onset <55 years in male first-degree relative or <65 years in female first-degree relative) 1, 2
- Primary LDL-C ≥160 mg/dL or other genetic hyperlipidemias 1
- High-sensitivity C-reactive protein ≥2 mg/L 1, 2
- Metabolic syndrome 2
- Chronic kidney disease 1
- Chronic inflammatory disorders 2
- Ankle-brachial index <0.9 2
Coronary Artery Calcium (CAC) Scoring Algorithm
For intermediate-risk (≥7.5% to <20%) or selected borderline-risk (5% to <7.5%) patients when treatment decision is uncertain 1:
- CAC score = 0: Withhold statin therapy and reassess in 5-10 years (unless higher-risk conditions present: diabetes, family history of premature CHD, cigarette smoking) 1
- CAC score 1-99: Initiate statin therapy for patients ≥55 years of age 1
- CAC score ≥100 or ≥75th percentile: Initiate statin therapy 1
Lifestyle Interventions (Foundation for All Patients)
Dietary Recommendations
- Emphasize vegetables, fruits, nuts, whole grains, lean protein, and fish 1
- Minimize trans fats, processed meats, refined carbohydrates, and sweetened beverages 1
- Reduce cholesterol-raising saturated fatty acids and dietary cholesterol for LDL-C lowering 3
- Restrict alcohol, added sugars, and refined starches for triglyceride management 3
Physical Activity
- At least 150 minutes per week of moderate-intensity physical activity 1
- OR 75 minutes per week of vigorous-intensity physical activity 1
Weight Management
- Counseling and caloric restriction for adults with overweight and obesity 1
Tobacco Cessation
- Assess tobacco use at every healthcare visit 1
- Strongly advise and assist all tobacco users to quit 1
Blood Pressure Management
- Target BP <130/80 mm Hg for most patients requiring pharmacologic therapy 1
- Nonpharmacological interventions recommended for all adults with elevated BP or hypertension 1
Aspirin for Primary Prevention
- Use aspirin infrequently in routine primary prevention due to lack of net benefit 1
- Risk of bleeding generally outweighs ASCVD risk reduction in primary prevention populations 1
Diabetes Management Beyond Glycemic Control
- Lifestyle changes (diet and exercise) are crucial 1
- Metformin is first-line pharmacologic therapy 1
- Consider SGLT-2 inhibitor or GLP-1 receptor agonist for patients with additional ASCVD risk factors requiring glucose-lowering therapy despite metformin 1
Special Populations
Asian Patients
- Initiate rosuvastatin at 5 mg once daily due to increased plasma concentrations 4
- Consider risks and benefits when treating Asian patients not adequately controlled at doses up to 20 mg daily 4
Severe Renal Impairment (CrCl <30 mL/min/1.73 m²)
Critical Pitfalls to Avoid
- Do not delay statin initiation in patients with ≥7.5% 10-year ASCVD risk—robust RCT evidence supports treatment at this threshold 2
- Do not use age alone as a reason to withhold statins, as most ASCVD events occur after age 70 2
- Do not target specific LDL-C goals in primary prevention—focus on achieving appropriate statin intensity instead 2
- Do not discontinue statins if patients cannot tolerate intended intensity—use maximum tolerated dose rather than stopping completely 2
- Do not forget lifestyle emphasis even when prescribing medications—lifestyle goals should be reinforced regularly 1
Clinician-Patient Risk Discussion
Before initiating pharmacologic therapy, engage in a discussion addressing 1, 2:
- Potential for ASCVD risk reduction
- Adverse effects of therapy
- Drug-drug interactions
- Patient preferences and values
- Presence of risk-enhancing factors