What is the first-line treatment for individuals not at high risk for Atherosclerotic Cardiovascular Disease (ASCVD)?

First-Line Treatment for Individuals NOT at High Risk for ASCVD

Lifestyle modification is the foundation and first-line treatment for individuals not at high risk for ASCVD, including adherence to a heart-healthy diet, regular exercise, avoidance of tobacco, and maintenance of healthy weight. 1, 2

Lifestyle Interventions as Primary Treatment

For individuals not meeting criteria for high-risk ASCVD, therapeutic lifestyle changes form the cornerstone of management:

Dietary Modifications

• Emphasize a Mediterranean or DASH eating pattern with vegetables, fruits, nuts, whole grains, lean protein, and fish 2, 3
• Minimize trans fats, processed meats, refined carbohydrates, and sweetened beverages 2
• Reduce saturated fat intake and increase dietary omega-3 fatty acids, viscous fiber, and plant stanols/sterols 3

Physical Activity

• Engage in at least 150 minutes per week of moderate-intensity physical activity or 75 minutes per week of vigorous-intensity physical activity 2
• The American College of Cardiology recommends 150-300 minutes of moderate-intensity or 75-150 minutes of vigorous-intensity exercise weekly 4

Weight Management

• Counsel and assist adults with overweight and obesity to achieve weight loss through caloric restriction 2

Tobacco Cessation

• Complete avoidance of tobacco products is essential 1
• Provide smoking cessation counseling and consider pharmacotherapy (nicotine replacement, varenicline, or bupropion) for current smokers 4

Risk Stratification Before Pharmacologic Therapy

Adults aged 40-75 years should undergo 10-year ASCVD risk estimation before starting any pharmacologic therapy to determine if they qualify for statin treatment 1, 2, 3

When Statin Therapy May Be Considered (Even in "Not High Risk")

The guidelines define specific thresholds where pharmacologic therapy becomes appropriate:

• For primary prevention without diabetes (age 40-75, LDL-C 70-189 mg/dL): Estimate 10-year ASCVD risk using the Pooled Cohort Equations 1, 3
• If 10-year ASCVD risk is ≥7.5% but <20% (intermediate risk): Engage in clinician-patient risk discussion addressing potential benefits, adverse effects, patient preferences, and risk-enhancing factors before initiating moderate-intensity statin therapy 1, 2, 4
• If 10-year ASCVD risk is 5-7.5% (borderline risk): Consider risk-enhancing factors (family history of premature ASCVD, persistently elevated LDL-C ≥160 mg/dL, chronic inflammatory conditions, high-sensitivity CRP ≥2 mg/L, coronary artery calcium score) before deciding on statin therapy 1, 3

Important Caveat on Risk Assessment

Reassess ASCVD risk every 4-6 years in those not receiving statin therapy to identify when risk thresholds are crossed 1, 2

Blood Pressure Management

Even in lower-risk individuals, hypertension requires attention:

• Target blood pressure <130/80 mmHg for most patients requiring pharmacologic therapy 2
• Nonpharmacological interventions (dietary sodium restriction <2.0 g/day, weight normalization, regular exercise) are recommended for all adults with elevated blood pressure 1, 2

Aspirin for Primary Prevention

Use aspirin infrequently in routine primary prevention due to lack of net benefit - the risk of bleeding generally outweighs ASCVD risk reduction in primary prevention populations 2

Key Distinction: Who Does NOT Need Statins

Individuals truly "not at high risk" include those with:

• 10-year ASCVD risk <5% (low risk) 1
• No diabetes mellitus 1
• LDL-C <190 mg/dL 1
• No clinical ASCVD 1

For these individuals, lifestyle modification alone is appropriate first-line treatment without pharmacologic therapy 1, 2

Monitoring and Follow-Up

• Lifestyle adherence should be reinforced at regular intervals 1
• Lipid panels and risk factor assessment should be repeated every 4-6 years to reassess whether pharmacologic intervention becomes indicated 1, 2