AHA - Dyslipidemia Primary Prevention Guidelines

Dyslipidemia Primary Prevention Guidelines (focusing on preventing first cardiovascular events)

1. Cardiovascular Risk Assessment

• All adults should have their ASCVD risk estimated using a validated risk calculator (e.g., ACC/AHA pooled cohort risk score, QRISK3, Framingham Risk Score) to guide prevention strategies. Risk factors include age, sex, blood pressure, smoking, diabetes, lipid levels, family history, and others. 

• Reassess risk periodically (e.g., every 4–6 years in adults without disease). 

2. Lifestyle Modification (First-Line in All Individuals)

• Healthy diet: Emphasize vegetables, fruits, whole grains, lean proteins, legumes, nuts; reduce saturated fat, trans fats and dietary cholesterol. 

• Physical activity: ≥150 minutes/week of moderate-intensity or ≥75 minutes/week of vigorous aerobic exercise. 

• Weight management: Aim for BMI 18.5–24.9 and waist circumference reduction. 

• Smoking cessation and blood pressure/glucose control. 

3. Lipid Targets & Risk Stratification (European & Other Guidelines)

• LDL-C remains the primary target for risk reduction — “lower is better.” 

• Risk categories define targets:

Low risk: LDL-C goal < 3.0 mmol/L (≈116 mg/dL)

Moderate risk: LDL-C goal < 2.6 mmol/L (≈100 mg/dL)

High risk: LDL-C goal < 1.8 mmol/L (≈70 mg/dL)

Very high risk (rare in primary prevention): aim ≥50 % reduction and LDL-C < 1.4 mmol/L (≈55 mg/dL) when appropriate. 

4. Statin Therapy for Primary Prevention

• General adult guidelines (ACC/AHA) recommend statin consideration based on 10-year ASCVD risk and LDL-C levels: 

LDL-C ≥190 mg/dL (4.9 mmol/L) — initiate high-intensity statin regardless of risk.

Age 40-75 with LDL-C ≥70 mg/dL (1.8 mmol/L) and 10-year risk ≥7.5 % — discuss and usually initiate statin.

Risk 5-7.5 % with risk-enhancing factors — consider moderate-intensity statin.

Age <40 or >75 — clinical judgment; focus on lifetime risk (younger) or careful assessment (older). 

• USPSTF recommendations (U.S.): 

Adults 40–75 years with ≥1 CVD risk factor and ≥10 % 10-year risk → Initiate moderate-intensity statin (Grade B).

7.5–<10 % risk → Consider statin after shared decision-making (Grade C).

≥76 years → Evidence insufficient to make a routine recommendation.

5. Risk-Enhancing Factors to Inform Decisions

• Family history of premature ASCVD, chronic kidney disease, metabolic syndrome, inflammatory disorders, South Asian ancestry. 

• Consider additional biomarkers (Lp(a), hs-CRP, etc.) and coronary artery calcium (CAC) scoring to refine risk in borderline cases. 

6. Non-Statin Options

• If statins are contraindicated or not tolerated, consider:

Ezetimibe

Bempedoic acid (with/without ezetimibe) as supported in some healthcare systems. 

• PCSK9 inhibitors generally reserved for very high risk and tolerated patients.

7. Other Primary Prevention Measures

• Aspirin is generally not recommended for routine primary prevention due to bleeding risk unless very specific high-risk profiles justify it. 

• Address other modifiable risk factors (blood pressure, glucose).

8. Follow-Up & Monitoring

• After initiating therapy, re-check lipids 6–12 weeks to assess response and adjust therapy.

• Monitor adherence, side effects (e.g., statin intolerance), and re-estimate risk over time.

These principles synthesize major guideline recommendations from ACC/AHA, USPSTF, ESC/EAS, NICE, and others for primary prevention of cardiovascular disease through dyslipidemia management.