Hyperlipidemia Screening & Statin Therapy (ACC/AHA 2018)

Algorithm Steps

1. ▶

   Start

   Lipid Screening

   Fasting lipid panel in adults 20+ years

   1. ◆

      Decision

      Clinical ASCVD Present?

      History of MI, stroke, PAD, or coronary revascularization

      1. ●

         Action

         Secondary Prevention

         High-intensity statin for all clinical ASCVD

         • Atorvastatin 40-80mg or Rosuvastatin 20-40mg
         • LDL goal <70 (very high risk <55)
         • Add ezetimibe if not at goal
         • Consider PCSK9i if LDL ≥70 on max therapy
         1. ●

            Action

            Follow-Up

            Recheck lipids 4-12 weeks after starting/adjusting

            • Assess LDL response and adherence
            • Monitor for muscle symptoms
            • Check LFTs if symptoms
            • Annual lipid panel once stable
      2. ◆

         Decision

         LDL-C Level

         Classify by LDL-C

         • ≥190 = Severe hypercholesterolemia
         • 70-189 = Calculate 10-year risk
         1. ●

            Action

            LDL ≥190 mg/dL

            High-intensity statin without risk calculation

            • Atorvastatin 40-80mg or Rosuvastatin 20-40mg
            • Screen for familial hypercholesterolemia
            • Consider cascade screening family
            • Refer to lipid specialist if refractory
         2. ◆

            Decision

            Diabetes Present?

            Ages 40-75 with DM

            1. ●

               Action

               Diabetes + Age 40-75

               Moderate-intensity statin minimum

               • Moderate: Atorvastatin 10-20mg, Rosuvastatin 5-10mg
               • Consider high-intensity if multiple risk factors
               • LDL goal <100 (or <70 if high risk)
               • DM is ASCVD risk equivalent in guidelines
               1. ●

                  Action

                  Calculate 10-Year ASCVD Risk

                  Use PCE calculator (ages 40-75, LDL 70-189)

                  • pooledcohortequations.org
                  • Inputs: age, sex, race, total cholesterol, HDL, SBP, DM, smoking, BP treatment
                  • Risk <5% = Low, 5-7.5% = Borderline, 7.5-20% = Intermediate, ≥20% = High
                  1. ✓

                     Outcome

                     Risk <5%

                     Lifestyle modification, reassess 4-6 years

                  2. ●

                     Action

                     Risk 5-7.5%

                     Risk discussion, consider enhancers

                     • Risk enhancers: family hx premature ASCVD, metabolic syndrome, CKD, inflammatory conditions, elevated Lp(a), ABI <0.9
                     • If enhancers present, favor statin therapy
                     • CAC score can guide if uncertain
                  3. ●

                     Action

                     Risk 7.5-20%

                     Moderate-intensity statin if risk discussion favors

                     • Consider CAC scoring to refine risk
                     • CAC = 0 may defer statin (unless DM, family hx)
                     • CAC 1-99 favors statin
                     • CAC ≥100 strongly favors statin
                  4. ●

                     Action

                     Risk ≥20%

                     High-intensity statin to reduce LDL ≥50%

                     • Atorvastatin 40-80mg or Rosuvastatin 20-40mg
                     • Goal: ≥50% LDL reduction
                     • Add ezetimibe if needed for LDL <70
                     • Risk discussion still important