Medical and Pharmacologic Therapy

Choices for pharmacologic therapy should be guided by a 10-year global risk assessment score for ASCVD or coronary heart disease using established risk equations (eg, the Framingham risk calculator, PROCAM risk algorithm, Systematic Coronary Risk Evaluation risk chart). Thresholds for high and moderate 10-year ASCVD risk were adjusted for this guideline update (>7.5% and 5%-7.5%, respectively) from the 2008 cutoffs.

Before considering primary hyperlipidemia, clinicians should rule out secondary causes of hyperlipidemia in patients with low-density lipoprotein cholesterol (LDL-C) level ≥190 mg/dL or triglyceride level ≥500 mg/dL.

With regard to LDL-C reduction, high-intensity statins (daily dose lowers LDL-C by ≥50%) should be prescribed for patients aged 40 to 75 with LDL-C ≥190 mg/dL. For patients with LDL-C between 70 and 189 mg/dL, the Society recommends varying levels of statin therapy intensity based on 10-year ASCVD risk. For patients at high risk for ASCVD, high-intensity statin therapy should be prescribed to achieve LDL-C <100 mg/dL; in those at a moderate risk, moderate-intensity statin therapy (daily dose lowers LDL-C by approximately 30%-≥50%) should be prescribed to achieve LDL-C <130 mg/dL, with consideration given to drug interactions, side effects, and patient preferences.

In individuals with a high 10-year ASCVD risk who have LDL-C levels at target and no clinical ASCVD, the guidelines also suggest the use of moderate-intensity statin therapy.

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Healthcare providers can also consider the use of fenofibrate adjunct therapy in patients at metabolic risk who achieve adequate LDL-C reductions on statin therapy but who have elevated triglyceride level and low HDL-C level.

With regard to blood pressure targets, patients at high metabolic risk with blood pressure >130/80 mm Hg and a 10-year ASCVD risk >10% should receive antihypertensive therapy in addition to lifestyle modifications. When 10-year ASCVD risk is ≤10% in patients with hypertension, lifestyle management is recommended to reduce blood pressure to <130/80 mm Hg.

Lifestyle modification should also be the first-line therapy to reduce glucose levels in individuals with prediabetes. For those who do not respond, metformin should be used as the first pharmacologic approach.

The use of aspirin for ASCVD prevention in patients at metabolic risk is no longer recommended because of lack of sufficient evidence supporting its benefit.

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Reference

Rosenzweig JL, Bakris GL, Berglund LF, et al. Primary prevention of ASCVD and T2DM in patients at metabolic risk: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2019;104(9):1-47.