What is the recommended treatment for an adult patient with a high Atherosclerotic Cardiovascular Disease (ASCVD) score, indicating a 10-year risk of cardiovascular events of 7.5% or higher?

Statin Therapy for Adults with ASCVD Risk ≥7.5%

For adults aged 40-75 years with a 10-year ASCVD risk of 7.5% or higher and LDL-C ≥70 mg/dL, initiate moderate-intensity statin therapy after conducting a clinician-patient risk discussion. 1, 2

Risk-Based Treatment Algorithm

Immediate Statin Initiation (No Risk Calculation Needed)

• LDL-C ≥190 mg/dL: Start high-intensity statin therapy immediately, targeting ≥50% LDL-C reduction 1, 2
• Diabetes mellitus (ages 40-75) with LDL-C ≥70 mg/dL: Start at least moderate-intensity statin therapy; consider high-intensity if multiple risk factors present 1, 2
• Clinical ASCVD: Initiate maximally tolerated high-intensity statin therapy 2

Risk-Stratified Statin Therapy (Ages 40-75, LDL-C 70-189 mg/dL)

High Risk (≥20% 10-year ASCVD risk)

• Start high-intensity statin therapy targeting ≥50% LDL-C reduction 1, 2
• Number needed to treat: approximately 20-30 to prevent one ASCVD event over 10 years 2

Intermediate Risk (7.5% to <20% 10-year ASCVD risk)

• Start moderate-intensity statin therapy targeting ≥30% LDL-C reduction 1, 2
• This is a Class I recommendation with Level A evidence 1, 2
• Number needed to treat: 36-44 to prevent one ASCVD event over 10 years 2
• Number needed to harm for diabetes: 100 2
• The absolute benefit clearly outweighs potential adverse effects at this threshold 1

Borderline Risk (5% to <7.5% 10-year ASCVD risk)

• Consider moderate-intensity statin therapy if risk-enhancing factors are present 1, 2
• Number needed to treat: 57-67 2
• If no risk-enhancing factors, emphasize lifestyle modifications and consider CAC scoring 1, 3

Low Risk (<5% 10-year ASCVD risk)

• Statin therapy generally not indicated unless specific risk-enhancing factors present 2, 3
• Focus on lifestyle modifications 3

Risk-Enhancing Factors That Lower Treatment Threshold

When ASCVD risk is borderline or lower intermediate, the presence of these factors favors statin initiation: 1, 2

• Family history of premature ASCVD (male <55 years, female <65 years) 1, 2
• Persistently elevated LDL-C ≥160 mg/dL 1, 2
• Metabolic syndrome 2
• Chronic kidney disease 2
• History of preeclampsia or premature menopause 2
• Chronic inflammatory disorders (rheumatoid arthritis, psoriasis, HIV) 2
• High-risk ethnic groups (South Asian ancestry) 2
• Persistent triglycerides ≥175 mg/dL 2
• High-sensitivity C-reactive protein ≥2 mg/L 2
• Ankle-brachial index <0.9 2

Using Coronary Artery Calcium (CAC) Scoring for Uncertain Decisions

When the statin decision remains uncertain in intermediate-risk (7.5%-19.9%) or selected borderline-risk patients: 1, 2

• CAC = 0: Reasonable to withhold or delay statin therapy (10-year event rate ~1.5%), except in patients with diabetes, family history of premature ASCVD, or current smoking 1, 2
• CAC 1-99: Favors statin therapy, especially in patients ≥55 years of age 1, 2
• CAC ≥100 or ≥75th percentile: Statin therapy is warranted 1, 2
• Reassess CAC in 5-10 years if initially zero and statin withheld 1

Specific Statin Recommendations

Moderate-Intensity Statins (30% to <50% LDL-C reduction): 1, 2

• Atorvastatin 10-20 mg daily
• Rosuvastatin 5-10 mg daily
• Simvastatin 20-40 mg daily
• Pravastatin 40-80 mg daily

High-Intensity Statins (≥50% LDL-C reduction): 1, 2

• Atorvastatin 40-80 mg daily
• Rosuvastatin 20-40 mg daily

Mandatory Clinician-Patient Risk Discussion

Before prescribing any statin, conduct a structured discussion addressing: 1, 2

• Review of major risk factors and calculated 10-year ASCVD risk 1, 2
• Presence of risk-enhancing factors 1, 2
• Potential ASCVD risk reduction benefits (20-30% relative risk reduction) 2
• Potential adverse effects: myalgias (most common), new-onset diabetes (0.1 excess cases per 100 person-years for moderate-intensity, 0.3 for high-intensity), rare myopathy (0.01 per 100), rare hemorrhagic stroke (0.01 per 100) 1, 2
• Drug-drug interactions and costs 1, 2
• Patient preferences, values, and ability to adhere 1, 2
• Emphasis that heart-healthy lifestyle is the foundation of ASCVD prevention 1, 2, 3

Monitoring and Follow-Up

• Assess adherence and LDL-C response 4-12 weeks after statin initiation or dose adjustment 1, 2
• Repeat lipid measurement every 3-12 months as needed based on adherence and safety 1
• Target LDL-C reduction: ≥30% for moderate-intensity, ≥50% for high-intensity statins 2
• Monitor for adverse effects including muscle symptoms, liver enzymes, and new-onset diabetes 1, 2

Critical Pitfalls to Avoid

• Do not prescribe statins based on risk calculation alone—the clinician-patient discussion is mandatory and must address benefits, harms, and patient preferences 1, 2
• Do not rely on age alone to drive decisions; consider the complete risk profile, life expectancy, and functional status 1, 2
• Do not ignore uncontrolled hypertension or other modifiable risk factors—addressing these is equally important as statin initiation 1
• Do not use LDL-C targets for titration—focus on statin intensity and percentage LDL-C reduction rather than specific LDL-C goals 1
• Do not overlook risk-enhancing factors in borderline-risk patients, as these substantially modify treatment decisions 1, 2

Special Populations

Older Adults (≥75 years):

• Moderate-intensity statin initiation may be reasonable if LDL-C 70-189 mg/dL 1
• Consider stopping statins when functional decline, multimorbidity, frailty, or reduced life expectancy limits potential benefits 1
• CAC scoring may help reclassify patients aged 76-80 with CAC = 0 to avoid statin therapy 1