Recommendations

Class

Level

CV risk estimation in persons without known CVD

SCORE2 is recommended in apparently healthy people <70 years of age without established ASCVD, DM, CKD, genetic/rare lipid or BP disorders for estimation of 10-year fatal and non-fatal CVD risk

I

B

SCORE2-OP is recommended in apparently healthy people ≥70 years of age without established ASCVD, DM, CKD, genetic/rare lipid or BP disorders for estimation of 10-year fatal and non-fatal CVD risk

I

B

Presence of subclinical coronary atherosclerosis by imaging or increased CAC score by CT should be considered as risk modifiers in individuals at moderate risk or individuals around treatment decision thresholds to improve risk classification

IIa

B

Risk modifiers should be considered in individuals at moderate risk or individuals around treatment decision thresholds to improve risk classification

IIa

B

Pharmacological LDL-C lowering in primary prevention

Pharmacological LDL-C-lowering therapy is recommended in very high-risk persons with LDL-C ≥1.8mmol/L, or high-risk persons with LDL-C ≥2.6mmol/L (100mg/dL) despite optimization of non-pharmacological measures, to lower CVD risk

I

A

Pharmacological LDL-C-lowering therapy should be considered in very high-risk persons with LDL-C ≥1.4 but <1.8mmol/L, high-risk with LDL-C ≥1.8 but <2.6mmol/L, moderate-risk with LDL-C ≥2.6 but <4.9mmol/L, or low-risk with LDL-C ≥3.0 but <4.9mmol/L despite non-pharmacological optimization, to lower CVD risk

IIa

A

Non-statin therapies with proven CV benefit, alone or in combination, are recommended for patients unable to take statins to lower LDL-C levels and reduce the risk of CV events. The choice should be based on the magnitude of additional LDL-C lowering needed

I

A

Bempedoic acid is recommended in patients unable to take statins to achieve LDL-C goal

I

B

The addition of bempedoic acid to maximally tolerated statin ± ezetimibe should be considered in high or very high-risk patients not at LDL-C goal

IIa

C

Evinacumab should be considered in patients with homozygous familial hypercholesterolemia ≥5 years not at LDL-C goal despite maximum doses of lipid-lowering therapy to lower LDL-C levels

IIa

B

Pharmacological LDL-C lowering in ACS

Intensification of lipid-lowering therapy during index ACS hospitalization is recommended for patients previously on lipid-lowering therapy before admission in order to further lower LDL-C levels

I

C

Initiating combination therapy with high-intensity statin plus ezetimibe during index ACS hospitalization should be considered in treatment-naïve patients not expected to achieve LDL-C goal with statin alone

IIa

B

Measurement of Lp(a)

Lp(a) levels above 50mg/dL (105nmol/L) should be considered in all adults as a CV risk-enhancing factor, with higher Lp(a) levels associated with a greater increase in risk

IIa

B

Drug treatment of patients with hypertriglyceridemia

High-dose icosapent ethyl (2 × 2g/day) should be considered with a statin in high- or very high-risk patients with fasting triglycerides 135-499mg/dL (1.52-5.63mmol/L) to reduce the risk of CV events

IIa

B

Volanesorsen (300mg/week) should be considered in patients with severe hypertriglyceridemia (>750mg/dL or >8.5mmol/L) due to familial chylomicronemia syndrome, to lower triglyceride levels and reduce the risk of pancreatitis

IIa

B

Special populations

Statin therapy is recommended in primary prevention for people ≥40 years with HIV, irrespective of risk and LDL-C, with statin choice based on potential drug interactions

I

B

Statins should be considered in adult patients receiving cancer therapy with high or very high-risk of developing chemotherapy-related CV toxicity to reduce the risk of anthracycline-induced cardiac dysfunction

IIa

B

Supplements

Dietary supplements or vitamins without documented safety and significant LDL-C-lowering efficacy are not recommended to lower ASCVD risk

III

B