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What is What aret the TOP 10 TAKE-HOME MESSAGES TO REDUCE RISKOF ATHEROSCLEROTIC CARDIOVASCULAR? and explain in detail?
1. In all individuals, emphasize a heart-healthy lifestyleacross the life course. A healthy lifestyle reducesatherosclerotic cardiovascular disease (ASCVD) risk atall ages. In younger individuals, healthy lifestyle canreduce development of risk factors and is the foundation of ASCVD risk reduction. In young adults 20 to39 years of age, an assessment of lifetime risk facilitates the clinician-patient risk discussion (see No. 6)and emphasizes intensive lifestyle efforts. In all agegroups, lifestyle therapy is the primary interventionfor metabolic syndrome.2. In patients with clinical ASCVD, reduce low-densitylipoprotein cholesterol (LDL-C) with high-intensitystatin therapy or maximally tolerated statin therapy. The more LDL-C is reduced on statin therapy, thegreater will be subsequent risk reduction. Use amaximally tolerated statin to lower LDL-C levelsby $50%.3. In very high-risk ASCVD, use a LDL-C threshold of 70mg/dL (1.8 mmol/L) to consider addition of nonstatins to statin therapy. Very high-risk includes ahistory of multiple major ASCVD events or 1 majorASCVD event and multiple high-risk conditions. Invery high-risk ASCVD patients, it is reasonable to addezetimibe to maximally tolerated statin therapy whenthe LDL-C level remains $70 mg/dL ($1.8 mmol/L). Inpatients at very high risk whose LDL-C levelremains $70 mg/dL ($1.8 mmol/L) on maximallytolerated statin and ezetimibe therapy, adding aPCSK9 inhibitor is reasonable, although the long-termsafety (>3 years) is uncertain and cost effectiveness islow at mid-2018 list prices.4. In patients with severe primary hypercholesterolemia (LDL-C level 190 mg/dL [4.9 mmol/L]),without calculating 10-year ASCVD risk, begin highintensity statin therapy. If the LDL-C levelremains $100 mg/dL ($2.6 mmol/L), adding ezetimibe is reasonable. If the LDL-C level on statin plusezetimibe remains $100 mg/dL ($2.6 mmol/L) andthe patient has multiple factors that increase subsequent risk of ASCVD events, a PCSK9 inhibitormay be considered, although the long-term safety(>3 years) is uncertain and economic value isuncertain at mid-2018 list prices.5. In patients 40 to 75 years of age with diabetes mellitus and LDL-C 70 mg/dL (1.8 mmol/L), startmoderate-intensity statin therapy without calculating 10-year ASCVD risk. In patients with diabetesmellitus at higher risk, especially those with multiplerisk factors or those 50 to 75 years of age, it isreasonable to use a high-intensity statin to reduce theLDL-C level by $50%.6. In adults 40 to 75 years of age evaluated for primaryASCVD prevention, have a clinician-patient risk discussion before starting statin therapy. Risk discussion should include a review of major risk factors(e.g., cigarette smoking, elevated blood pressure,LDL-C, hemoglobin A1C [if indicated], and calculated10-year risk of ASCVD); the presence of risk-enhancingfactors (see No. 8); the potential benefits of lifestyleand statin therapies; the potential for adverse effectsand drug-drug interactions; consideration of costs ofstatin therapy; and patient preferences and values inshared decision-making.7. In adults 40 to 75 years of age without diabetesmellitus and with LDL-C levels 70 mg/dL (1.8mmol/L), at a 10-year ASCVD risk of $7.5%, start amoderate-intensity statin if a discussion of treatmentoptions favors statin therapy. Risk-enhancing factorsfavor statin therapy (see No. 8). If risk status is uncertain, consider using coronary artery calcium (CAC)to improve specificity (see No. 9). If statins areJACC VOL. 73, NO. 24, 2019 Grundy et al.JUNE 25, 2019:e285-350 2018 Cholesterol Clinical Practice Guidelinee287indicated, reduce LDL-C levels by $30%, and if 10-year risk is $20%, reduce LDL-C levels by $50%.8. In adults 40 to 75 years of age withoutdiabetes mellitus and 10-year risk of 7.5% to 19.9%(intermediate risk), risk-enhancing factors favorinitiation of statin therapy (see No. 7). Riskenhancing factors include family history of premature ASCVD; persistently elevated LDL-C levels$160 mg/dL ($4.1 mmol/L); metabolic syndrome;chronic kidney disease; history of preeclampsia orpremature menopause (age <40 years); chronic inflammatory disorders (e.g., rheumatoid arthritis, psoriasis, or chronic HIV); high-risk ethnic groups (e.g.,South Asian); persistent elevations of triglycerides$175 mg/dL ($1.97 mmol/L); and, if measured inselected individuals, apolipoprotein B $130 mg/dL, highsensitivity C-reactive protein $2.0 mg/L, ankle-brachialindex <0.9 and lipoprotein (a) $50 mg/dL or 125 nmol/L,especially at higher values of lipoprotein (a).Risk-enhancing factors may favor statin therapyin patients at 10-year risk of 5-7.5% (borderline risk).9. In adults 40 to 75 years of age without diabetesmellitus and with LDL-C levels 70 mg/dL- 189 mg/dL(1.8-4.9 mmol/L), at a 10-year ASCVD risk of 7.5%to 19.9%, if a decision about statin therapy is uncertain, consider measuring CAC. If CAC is zero, treatment with statin therapy may be withheld or delayed,except in cigarette smokers, those with diabetesmellitus, and those with a strong family history ofpremature ASCVD. A CAC score of 1 to 99 favors statintherapy, especially in those $55 years of age. For anypatient, if the CAC score is $100 Agatston unitsor $75th percentile, statin therapy is indicated unlessotherwise deferred by the outcome of clinician-patient risk discussion.10. Assess adherence and percentage response to LDL-C-lowering medications and lifestyle changes withrepeat lipid measurement 4 to 12 weeks after statininitiation or dose adjustment, repeated every 3 to 12months as needed. Define responses to lifestyle andstatin therapy by percentage reductions in LDL-Clevels compared with baseline. In ASCVD patients atvery high-risk, triggers for adding nonstatin drugtherapy are defined by threshold LDL-C levels $70mg/dL ($1.8 mmol/L) on maximal statin therapy