2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults

HomeCirculationVol. 129, No. 25_suppl_22013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults Open AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialOpen AccessResearch ArticlePDF/EPUB2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in AdultsA Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Neil J. Stone, MD, MACP, FAHA, FACC, Jennifer G. Robinson, MD, MPH, FAHA, Alice H. Lichtenstein, DSc, FAHA, C. Noel Bairey Merz, MD, FAHA, FACC, Conrad B. Blum, MD, FAHA, Robert H. Eckel, MD, FAHA, Anne C. Goldberg, MD, FACP, FAHA, David Gordon, MD, Daniel Levy, MD, Donald M. Lloyd-Jones, MD, SCM, FACC, FAHA, Patrick McBride, MD, MPH, FAHA, J. Sanford Schwartz, MD, Susan T. Shero, MS, RN, Sidney C. SmithJr, MD, FACC, FAHA, Karol Watson, MD, PhD, FACC, FAHA and Peter W. F. Wilson, MD, FAHA Neil J. StoneNeil J. Stone Search for more papers by this author , Jennifer G. RobinsonJennifer G. Robinson Search for more papers by this author , Alice H. LichtensteinAlice H. Lichtenstein Search for more papers by this author , C. Noel Bairey MerzC. Noel Bairey Merz Search for more papers by this author , Conrad B. BlumConrad B. Blum Search for more papers by this author , Robert H. EckelRobert H. Eckel Search for more papers by this author , Anne C. GoldbergAnne C. Goldberg Search for more papers by this author , David GordonDavid Gordon Search for more papers by this author , Daniel LevyDaniel Levy *Ex-Officio Members. Search for more papers by this author , Donald M. Lloyd-JonesDonald M. Lloyd-Jones Search for more papers by this author , Patrick McBridePatrick McBride Search for more papers by this author , J. Sanford SchwartzJ. Sanford Schwartz Search for more papers by this author , Susan T. SheroSusan T. Shero *Ex-Officio Members. Search for more papers by this author , Sidney C. SmithJrSidney C. SmithJr Search for more papers by this author , Karol WatsonKarol Watson Search for more papers by this author and Peter W. F. WilsonPeter W. F. Wilson Search for more papers by this author Originally published12 Nov 2013https://doi.org/10.1161/01.cir.0000437738.63853.7aCirculation. 2014;129:S1–S45is corrected byCorrectionCorrectionOther version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2013: Previous Version 1 Table of ContentsPreamble and Transition to ACC/AHA Guidelines to Reduce Cardiovascular Risk S21. Introduction S31.1 Organization of the Panel S31.2 Document Review and Approval S31.3 Scope of Guideline S31.4 Methodology and Evidence Review S52. Overview of the Guideline S62.1. Lifestyle as the Foundation for ASCVD Risk-Reduction Efforts S62.2. Initiation of Statin Therapy S73. Critical Questions and Conclusions S103.1. Identification of CQs S103.1.1. CQ1: LDL-C and Non–HDL-C Goals in Secondary Prevention S103.1.2. CQ2: LDL-C and Non–HDL-C Goals in Primary Prevention S103.1.3. CQ3: Efficacy and Safety of Cholesterol-Lowering Medications S104. Statin Treatment: Recommendations S104.1. Intensity of Statin Therapy in Primary and Secondary Prevention S124.2. LDL-C and Non–HDL-C Treatment Goals S124.3. Secondary Prevention S134.4. Primary Prevention in Individuals ≥21 Years of Age With LDL-C ≥190 mg/dL S144.5. Primary Prevention in Individuals With Diabetes S164.6. Primary Prevention in Individuals Without Diabetes and With LDL-C 70 to 189 mg/dL S164.7. Risk Assessment in Primary Prevention S174.8. Heart Failure and Hemodialysis S175. Safety: Recommendations S186. Managing Statin Therapy: Recommendations S216.1. Monitoring Statin Therapy S216.2. Optimizing Statin Therapy S216.3. Insufficient Response to Statin Therapy S216.3.1 Testing S216.3.2 Nonstatins Added to Statins or in Statin-Intolerant Individuals S227. Selected Clinical and Population Subgroups S237.1. Sex and Racial and Ethnic Subgroups S237.2. Individuals >75 Years of Age S238. Limitations S249. Evidence Gaps and Future Research Needs S2410. Conclusions S24References S25Appendix 1. Author Relationships With Industry and Other Entities (Relevant) S28Appendix 2. Expert Reviewer Relationships With Industry and Other Entities S32Appendix 3. Abbreviations S33Appendix 4. Evidence Statements S33Appendix 5. Expanded Discussion of What’s New in the Guideline S43Preamble and Transition to ACC/AHA Guidelines to Reduce Cardiovascular RiskThe goals of the American College of Cardiology (ACC) and the American Heart Association (AHA) are to prevent cardiovascular diseases; improve the management of people who have these diseases through professional education and research; and develop guidelines, standards, and policies that promote optimal patient care and cardiovascular health. Toward these objectives, the ACC and AHA have collaborated with the National Heart, Lung, and Blood Institute (NHLBI) and stakeholder and professional organizations to develop clinical practice guidelines for assessment of cardiovascular risk, lifestyle modifications to reduce cardiovascular risk, management of blood cholesterol in adults, and management of overweight and obesity in adults.In 2008, the NHLBI initiated these guidelines by sponsoring rigorous systematic evidence reviews for each topic by expert panels convened to develop critical questions (CQs), interpret the evidence, and craft recommendations. In response to the 2011 report from the Institute of Medicine on the development of trustworthy clinical guidelines,1 the NHLBI Advisory Council recommended that the NHLBI focus specifically on reviewing the highest-quality evidence and partner with other organizations to develop recommendations.2,3 Accordingly, in June 2013 the NHLBI initiated collaboration with the ACC and AHA to work with other organizations to complete and publish the 4 guidelines noted above and make them available to the widest possible constituency. Recognizing that the Expert Panels/Work Groups did not consider evidence beyond 2011 (except as specified in the methodology), the ACC, AHA, and collaborating societies plan to begin updating these guidelines starting in 2014.The joint ACC/AHA Task Force on Practice Guidelines (Task Force) appointed a subcommittee to shepherd this transition, communicate the rationale and expectations to the writing panels and partnering organizations, and expeditiously publish the documents. The ACC/AHA and partner organizations recruited a limited number of expert reviewers for fiduciary examination of content, recognizing that each document had undergone extensive peer review by representatives of the NHLBI Advisory Council, key federal agencies, and scientific experts. Each writing panel responded to comments from these reviewers. Clarifications were incorporated where appropriate, but there were no substantive changes because the bulk of the content was undisputed.Although the Task Force led the final development of these prevention guidelines, they differ from other ACC/AHA guidelines. First, as opposed to an extensive compendium of clinical information, these documents are significantly more limited in scope and focus on selected CQs on each topic, based on the highest-quality evidence available. Recommendations were derived from randomized trials, meta-analyses, and observational studies evaluated for quality and were not formulated when sufficient evidence was not available. Second, the text accompanying each recommendation is succinct, summarizing the evidence for each question. The Full Panel/Work Group Reports include more detailed information about the evidence statements that serve as the basis for recommendations. Third, the format of the recommendations differs from other ACC/AHA guidelines. Each recommendation has been mapped from the NHLBI grading format to the ACC/AHA Classification of Recommendation/Level of Evidence (COR/LOE) construct (Table 1) and is expressed in both formats. Because of the inherent differences in grading systems and the clinical questions driving the recommendations, alignment between the NHLBI and ACC/AHA formats is in some cases imperfect. Explanations of these variations are noted in the recommendation tables, where applicable.Table 1. Applying Classification of Recommendation and Level of EvidenceTable 1. Applying Classification of Recommendation and Level of EvidenceIn consultation with NHLBI, the policies adopted by the writing panels to manage relationships of authors with industry and other entities (RWI) are outlined in the methods section of each panel report. These policies were in effect when this effort began in 2008 and throughout the writing process and voting on recommendations, until the process was transferred to ACC/AHA in 2013. In the interest of transparency, the ACC/AHA requested that panel authors resubmit RWI disclosures as of July 2013. Relationships relevant to this guideline are disclosed in Appendix 1. None of the ACC/AHA expert reviewers had relevant RWI (Appendix 2). See Appendix 3 for a list of abbreviations used in the guideline.Systematic evidence reports and accompanying summary tables were developed by the expert panels and NHLBI. The guideline was reviewed by the ACC/AHA Task Force and approved by the ACC Board of Trustees, and the AHA Science Advisory and Coordinating Committee. In addition, ACC/AHA sought endorsement from other stakeholders, including professional organizations. It is the hope of the writing panels, stakeholders, professional organizations, NHLBI, and Task Force that the guidelines will garner the widest possible readership for the benefit of patients, providers, and the public health.These guidelines are meant to define practices that meet the needs of patients in most circumstances and are not a replacement for clinical judgment. The ultimate decision about care of a particular patient must be made by the healthcare provider and patient in light of the circumstances presented by that patient. As a result, situations might arise in which deviations from these guidelines may be appropriate. These considerations notwithstanding, in caring for most patients, clinicians can employ the recommendations confidently to reduce the risks of atherosclerotic cardiovascular disease (ASCVD) events.See Tables 1a and 1b for an explanation of the NHLBI recommendation grading methodology.Table 1a. NHLBI Grading of the Strength of RecommendationsGradeStrength of Recommendation*AStrong recommendationThere is high certainty based on evidence that the net benefit‡ is substantial.BModerate recommendationThere is moderate certainty based on evidence that the net benefit is moderate to substantial, or there is high certainty that the net benefit is moderate.CWeak recommendationThere is at least moderate certainty based on evidence that there is a small net benefit.DRecommendation againstThere is at least moderate certainty based on evidence that there is no net benefit or that risks/harms outweigh benefits.EExpert opinion (“There is insufficient evidence or evidence is unclear or conflicting, but this is what the Work Group recommends.”)Net benefit is unclear. Balance of benefits and harms cannot be determined because of no evidence, insufficient evidence, unclear evidence, or conflicting evidence, but the Work Group thought it was important to provide clinical guidance and make a recommendation. Further research is recommended in this area.NNo recommendation for or against (“There is insufficient evidence or evidence is unclear or conflicting.”)Net benefit is unclear. Balance of benefits and harms cannot be determined because of no evidence, insufficient evidence, unclear evidence, or conflicting evidence, and the Work Group thought no recommendation should be made. Further research is recommended in this area.*In most cases, the strength of the recommendation should be closely aligned with the quality of the evidence; however, under some circumstances, there may be valid reasons for making recommendations that are not closely aligned with the quality of the evidence (eg, strong recommendation when the evidence quality is moderate, such as smoking cessation to reduce cardiovascular disease risk or ordering an ECG as part of the initial diagnostic work-up for a patient presenting with possible MI). Those situations should be limited and the rationale explained clearly by the Work Group.†Net benefit is defined as benefits minus risks/harms of the service/intervention.ECG indicates electrocardiogram; MI, myocardial infarction; and NHLBI, National Heart, Lung, and Blood Institute.Table 1b. NHLBI Quality Rating of the Strength of EvidenceType of EvidenceQuality Rating*Well-designed, well-executed‡ RCT that adequately represent populations to which the results are applied and directly assess effects on health outcomes.Meta-analyses of such studies.Highly certain about the estimate of effect. Further research is unlikely to change our confidence in the estimate of effect.>HighRCT with minor limitations‡ affecting confidence in, or applicability of, the results.Well-designed, well-executed nonrandomized controlled studies§ and well-designed, well-executed observational studies‖.Meta-analyses of such studies.Moderately certain about the estimate of effect. Further research may have an impact on our confidence in the estimate of effect and may change the estimate.>ModerateRCT with major limitations.Nonrandomized controlled studies and observational studies with major limitations affecting confidence in, or applicability of, the results.Uncontrolled clinical observations without an appropriate comparison group (eg, case series, case reports).Physiological studies in humans.Meta-analyses of such studies.Low certainty about the estimate of effect. Further research is likely to have an impact on our confidence in the estimate of effect and is likely to change the estimate.Low*In some cases, other evidence, such as large all-or-none case series (eg, jumping from airplanes or tall structures), can represent high- or moderate-quality evidence. In such cases, the rationale for the evidence rating exception should be explained by the Work Group and clearly justified.†“Well-designed, well-executed” refers to studies that directly address the question; use adequate randomization, blinding, and allocation concealment; are adequately powered; use intention-to-treat analyses; and have high follow-up rates.‡Limitations include concerns with the design and execution of a study that result in decreased confidence in the true estimate of the effect. Examples of such limitations include but are not limited to: inadequate randomization, lack of blinding of study participants or outcome assessors, inadequate power, outcomes of interest that are not prespecified for the primary outcomes, low follow-up rates, and findings based on subgroup analyses. Whether the limitations are considered minor or major is based on the number and severity of flaws in design or execution. Rules for determining whether the limitations are considered minor or major and how they will affect rating of the individual studies will be developed collaboratively with the methodology team.§Nonrandomized controlled studies refer to intervention studies where assignment to intervention and comparison groups is not random (eg, quasi-experimental study design).‖Observational studies include prospective and retrospective cohort, case-control, and cross-sectional studies.NHLBI indicates National Heart, Lung, and Blood Institute; and RCT, randomized controlled trials.1. Introduction1.1. Organization of the PanelThe Blood Cholesterol Expert Panel (Expert Panel) was originally convened as the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel IV) appointed by the NHLBI. The Expert Panel was composed of 13 members and 3 ex-officio members, which included primary care physicians, cardiologists, endocrinologists, and experts in clinical lipidology, clinical trials, cardiovascular epidemiology and nutrition, and guideline development. The Expert Panel chair asked all panel members to disclose any conflict-of-interest information to the full panel in advance of the deliberations; members with conflicts were asked to recuse themselves from voting on any aspect of the guideline for which a conflict might exist. All 16 members of the NHLBI Adult Treatment Panel IV Panel transitioned to the ACC/AHA guideline Expert Panel. Independent contractors performed the systematic review with the assistance of the Expert Panel and provided methodological guidance to the Expert Panel.1.2. Document Review and ApprovalA formal peer review process was initially completed under the auspices of the NHLBI and included 23 expert reviewers and representatives of federal agencies. This document was also reviewed by 4 expert reviewers nominated by the ACC and the AHA when the management of the guideline transitioned to the ACC/AHA. The ACC and AHA reviewers’ RWI information is published in this document (Appendix 2).This document was approved for publication by the governing bodies of the ACC and AHA and endorsed by the American Academy of Physician Assistants, American Association of Cardiovascular and Pulmonary Rehabilitation, American Pharmacists Association, American Society for Preventive Cardiology, Association of Black Cardiologists, Preventive Cardiovascular Nurses Association, and WomenHeart: The National Coalition for Women with Heart Disease.1.3. Scope of GuidelineThis guideline is based on the Full Panel Report, which is provided as an online-only data supplement to the guideline. The Full Panel Report contains background and additional material related to content, methodology, evidence synthesis, rationale, and references and is supported by the NHLBI Systematic Evidence Review, which can be found at http://www.nhlbi.nih.gov/guidelines/cholesterol/ser/. Table 2 provides an overview to facilitate understanding what is new in the present guideline.Table 2. What’s New in the Guideline?*Focus on ASCVD Risk Reduction: 4 Statin Benefit GroupsThis guideline is based on a comprehensive set of data from RCTs from which 4 statin benefit groups were identified that focus efforts to reduce ASCVD events in secondary and primary prevention.This guideline identifies high-intensity and moderate-intensity statin therapy for use in secondary and primary prevention.A New Perspective on LDL-C and/or Non–HDL-C Treatment GoalsThe Expert Panel was unable to find RCT evidence to support continued use of specific LDL-C or non–HDL-C treatment targets.The appropriate intensity of statin therapy should be used to reduce ASCVD risk in those most likely to benefit.Nonstatin therapies, as compared with statin therapy, do not provide acceptable ASCVD risk-reduction benefits relative to their potential for adverse effects in the routine prevention of ASCVD.Global Risk Assessment for Primary PreventionThis guideline recommends use of the new Pooled Cohort Equations to estimate 10-year ASCVD risk in both white and black men and women.By more accurately identifying higher-risk individuals for statin therapy, the guideline focuses statin therapy on those most likely to benefit.It also indicates, on the basis of RCT data, those high-risk groups that might not benefit.This guideline recommends a discussion between clinicians and patients before initiation of statin therapy.Safety RecommendationsThis guideline used RCTs to identify important safety considerations in individuals receiving treatment of blood cholesterol to reduce ASCVD risk.Using RCTs to determine statin adverse effects facilitates understanding of the net benefit from statin therapy.This guideline provides expert guidance on management of statin-associated adverse effects, including muscle symptoms.Role of Biomarkers and Noninvasive TestsTreatment decisions in selected individuals who are not included in the 4 statin benefit groups may be informed by other factors as recommended by the Risk Assessment Work Group and Blood Cholesterol Expert Panel.Future Updates to the Blood Cholesterol GuidelineThis is a comprehensive guideline for the evidence-based treatment of blood cholesterol to reduce ASCVD risk.Future updates will build on this foundation to provide expert guidance on the management of complex lipid disorders and incorporate refinements in risk stratification based on critical review of emerging data.RCTs comparing alternative treatment strategies are needed in order to inform future evidence-based guidelines for the optimum ASCVD risk-reduction approach.*See Appendix 5, for an expanded discussion of what’s new in the guideline.ASCVD indicates atherosclerotic cardiovascular disease; HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol; and RCT, randomized controlled trial.The Expert Panel was charged with using data from randomized controlled trials (RCTs) and systematic reviews and meta-analyses of RCTs to update the clinical practice recommendations for the treatment of blood cholesterol levels to reduce ASCVD risk. For this guideline, ASCVD includes coronary heart disease (CHD), stroke, and peripheral arterial disease, all of presumed atherosclerotic origin. These recommendations are intended to provide a strong, evidence-based foundation for the treatment of cholesterol for the primary and secondary prevention of ASCVD in women and men.Because RCT data were used to identify those most likely to benefit from cholesterol-lowering statin therapy, the recommendations will be of value to primary care clinicians as well as specialists concerned with ASCVD prevention. Importantly, the recommendations were designed to be easy to use in the clinical setting, facilitating the implementation of a strategy of risk assessment and treatment focused on the prevention of ASCVD. The present guideline is intended to address treatment of adults (≥21 years of age) to complement the NHLBI cardiovascular health risk-reduction guideline for children and adolescents.4The members of the Expert Panel acknowledge the important contributions arising from decades of genetic and biochemical studies, observational epidemiological and ecological studies, and in vitro and animal experiments that associated higher low-density lipoprotein cholesterol (LDL-C) levels with greater ASCVD risk. These studies provided the rationale for RCTs, which in turn demonstrated that lowering cholesterol levels reduced ASCVD events and thereby established a central, causal role of atherogenic cholesterol-containing lipoprotein particles, particularly LDL, in the genesis of CHD and ASCVD.Other strategies for using drug therapy to reduce ASCVD events have been advocated, including treat-to-cholesterol target, lowest-is-best, and risk-based treatment approaches. However, only 1 approach has been evaluated in multiple RCTs—the use of fixed doses of cholesterol-lowering drugs to reduce ASCVD risk. Because the overwhelming body of evidence came from statin RCTs, the Expert Panel appropriately focused on these statin RCTs to develop evidence-based guidelines for the reduction of ASCVD risk. We recognize that this represents a significant departure from current strategies. This should not come as a surprise to clinicians. The recent guideline on heart failure has changed long-standing paradigms on the basis of the evidence, and this guideline does as well.5 Future RCTs will be needed to determine the optimal treatment strategy to provide the greatest reduction in ASCVD events with best margin of safety.The Expert Panel acknowledges that our process did not provide for a comprehensive approach to the detection, evaluation, and treatment of lipid disorders as was done in the prior Adult Treatment Panel III Report.6 However, the present guideline was never intended to be a comprehensive approach to lipid management for purposes other than ASCVD risk reduction. A limited number of expert opinion recommendations were made only when RCT evidence was not present and after a thorough consideration of what the Expert Panel had learned from the RCTs. For the many questions about complex lipid disorders that are beyond the scope of our systematic evidence review, or for which little or no RCT data are available, it is anticipated that clinicians with lipid expertise can contribute to their management.1.4. Methodology and Evidence ReviewAlthough the Expert Panel was convened before the Institute of Medicine reports on practice guidelines, our evidence-based process followed most of the standards from the Institute of Medicine report, “Clinical Practice Guidelines We Can Trust.”1 The systematic review was limited to RCTs with ASCVD outcomes and systematic reviews and meta-analyses of RCTs with ASCVD outcomes. Observational studies and those with <18 months (CQ1 and CQ2) or <12 months (CQ3) of follow-up were excluded. Support was provided by a methodology contractor and a systematic review and general support contractor and included the following steps:The Expert Panel constructed CQs relevant to clinical practice.The Expert Panel identified (a priori) inclusion/exclusion criteria for each CQ.An independent contractor developed a literature search strategy, based on inclusion/exclusion criteria, for each CQ.An independent contractor executed a systematic electronic search of the published literature from relevant bibliographic databases for each CQ. The date range for the overall literature search was January 1, 1995, through December 1, 2009. However, RCTs with hard ASCVD outcomes of myocardial infarction (MI), stroke, and cardiovascular death published after that date range were eligible for consideration until the Expert Panel began deliberations on relevant recommendations.RCTs that met the inclusion criteria and were independently graded as fair or good quality were included in the evidence tables for the consideration of the Expert Panel. RCTs that were graded as poor quality were excluded.With the assistance of independent methodologists, this evidence base was used to develop a series of evidence statements graded on the level of the evidence (high, medium, or low).The Expert Panel then synthesized the evidence statements into treatment recommendations/summaries graded as A (strong), B (moderate), C (weak), D (recommend against), E (expert), and N (no recommendation).The final evidence statements and treatment recommendations were approved by at least a majority of voting members of the Expert Panel.Guideline implementability appraisals, planned and coordinated by the NHLBI Implementation Work Group, were performed to identify and address barriers to guideline implementation.In addition, the Expert Panel was able to include major RCTs and meta-analyses of RCTs published through July 2013 in our discussion and as part of the process of determining ACC/AHA grading of the NHLBI expert-level recommendations.2. Overview of the GuidelineThe RCTs identified in the systematic evidence review indicated a consistent reduction in ASCVD events from 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitor (statin) therapy in secondary- and primary-prevention populations, with the exception of no ASCVD event reduction when statin therapy was initiated in those with New York Heart Association class II to IV heart failure or those receiving maintenance hemodialysis. The RCTs either compared fixed doses of statins with placebo or untreated controls, or compared fixed doses of higher-intensity statins with moderate-intensity statins. These trials were not designed to evaluate the effect of titrated (dose-adjusted) statin treatment to achieve prespecified LDL-C or non–HDL-C goals.Therefore, the Expert Panel was unable to find RCT evidence to support titrating cholesterol-lowering drug therapy to achieve target LDL-C or non–HDL-C levels, as recommended by Adult Treatment Panel III.6–8 Notably, the Expert Panel did find RCT evidence that use of therapy (eg, niacin) to additionally lower non–HDL-C, once an LDL-C target was achieved, did not further reduce ASCVD outcomes.9 The Expert Panel also found extensive RCT evidence that the appropriate intensity of statin therapy should be used to reduce ASCVD risk in those most likely to benefit. The work of the Expert Panel was informed by the reports of the Lifestyle Management10 and Risk Assessment Work Groups11 (Figure 1). A summary of the major recommendations for the treatment of cholesterol to reduce ASCVD risk are provided in Table 3.Table 3. Summary of Key Recommendations for the Treatment of Blood Cholesterol to Reduce ASCVD Risk in Adults (See Tables 4, 8, 9, and 10 for the complete recommendations; and Table 5 for definition of statin intensity)Table 3. Summary of Key Recommendations for the Treatment of Blood Cholesterol to Reduce ASCVD Risk in Adults (See Tables 4, 8, 9, and 10 for the complete recommendations; and Table 5 for definition of statin intensity)Table 4. Recommendations for Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults—Statin Treatment (High, Moderate, and Low Statin Intensities are Defined in Table 5)Table 4. Recommendations for Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults—Statin Treatment (High, Moderate, and Low Statin Intensities are Defined in Table 5)Table 5. High-, Moderate-, and Low-Intensity Statin Therapy (Used in the RCTs Reviewed by the Expert Panel)*High-Intensity Statin TherapyModerate-Intensity Statin TherapyLow-Intensity Statin TherapyDaily dose lowers LDL-C, on average, by approximately ≥50%