<s> [INST] <<SYS>> You are a helpful, respectful, and honest assistant. Always answer as helpfully as possible, while being safe. Your answers should not include any harmful, unethical, racist, sexist, toxic, dangerous, or illegal content. Please ensure that your responses are socially unbiased and positive in nature. If a question does not make any sense or is not factually coherent, explain why instead of answering something not correct. If you don't know the answer to a question, say that you don't know. Please don't share false information. <</SYS>>What aret the TOP 10 TAKE-HOME MESSAGES TO REDUCE RISK
OF ATHEROSCLEROTIC CARDIOVASCULAR? [/INST] 
1. In all individuals, emphasize a heart-healthy lifestyle
across the life course. A healthy lifestyle reduces
atherosclerotic cardiovascular disease (ASCVD) risk at
all ages. In younger individuals, healthy lifestyle can
reduce development of risk factors and is the foundation of ASCVD risk reduction. In young adults 20 to
39 years of age, an assessment of lifetime risk facilitates the clinician–patient risk discussion (see No. 6)
and emphasizes intensive lifestyle efforts. In all age
groups, lifestyle therapy is the primary intervention
for metabolic syndrome.
2. In patients with clinical ASCVD, reduce low-density
lipoprotein cholesterol (LDL-C) with high-intensity
statin therapy or maximally tolerated statin therapy. The more LDL-C is reduced on statin therapy, the
greater will be subsequent risk reduction. Use a
maximally tolerated statin to lower LDL-C levels
by $50%.
3. In very high-risk ASCVD, use a LDL-C threshold of 70
mg/dL (1.8 mmol/L) to consider addition of nonstatins to statin therapy. Very high-risk includes a
history of multiple major ASCVD events or 1 major
ASCVD event and multiple high-risk conditions. In
very high-risk ASCVD patients, it is reasonable to add
ezetimibe to maximally tolerated statin therapy when
the LDL-C level remains $70 mg/dL ($1.8 mmol/L). In
patients at very high risk whose LDL-C level
remains $70 mg/dL ($1.8 mmol/L) on maximally
tolerated statin and ezetimibe therapy, adding a
PCSK9 inhibitor is reasonable, although the long-term
safety (>3 years) is uncertain and cost effectiveness is
low 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 level
remains $100 mg/dL ($2.6 mmol/L), adding ezetimibe is reasonable. If the LDL-C level on statin plus
ezetimibe remains $100 mg/dL ($2.6 mmol/L) and
the patient has multiple factors that increase subsequent risk of ASCVD events, a PCSK9 inhibitor
may be considered, although the long-term safety
(>3 years) is uncertain and economic value is
uncertain 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), start
moderate-intensity statin therapy without calculating 10-year ASCVD risk. In patients with diabetes
mellitus at higher risk, especially those with multiple
risk factors or those 50 to 75 years of age, it is
reasonable to use a high-intensity statin to reduce the
LDL-C level by $50%.
6. In adults 40 to 75 years of age evaluated for primary
ASCVD 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 calculated
10-year risk of ASCVD); the presence of risk-enhancing
factors (see No. 8); the potential benefits of lifestyle
and statin therapies; the potential for adverse effects
and drug–drug interactions; consideration of costs of
statin therapy; and patient preferences and values in
shared decision-making.
7. In adults 40 to 75 years of age without diabetes
mellitus and with LDL-C levels ‡70 mg/dL (‡1.8
mmol/L), at a 10-year ASCVD risk of $7.5%, start a
moderate-intensity statin if a discussion of treatment
options favors statin therapy. Risk-enhancing factors
favor statin therapy (see No. 8). If risk status is uncertain, consider using coronary artery calcium (CAC)
to improve specificity (see No. 9). If statins are
JACC VOL. 73, NO. 24, 2019 Grundy et al.
JUNE 25, 2019:e285-350 2018 Cholesterol Clinical Practice Guideline
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indicated, 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 without
diabetes mellitus and 10-year risk of 7.5% to 19.9%
(intermediate risk), risk-enhancing factors favor
initiation 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 or
premature 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 in
selected individuals, apolipoprotein B $130 mg/dL, highsensitivity C-reactive protein $2.0 mg/L, ankle-brachial
index <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 therapy
in patients at 10-year risk of 5-7.5% (borderline risk).
9. In adults 40 to 75 years of age without diabetes
mellitus 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 diabetes
mellitus, and those with a strong family history of
premature ASCVD. A CAC score of 1 to 99 favors statin
therapy, especially in those $55 years of age. For any
patient, if the CAC score is $100 Agatston units
or $75th percentile, statin therapy is indicated unless
otherwise deferred by the outcome of clinician–
patient risk discussion.
10. Assess adherence and percentage response to LDL-C–
lowering medications and lifestyle changes with
repeat lipid measurement 4 to 12 weeks after statin
initiation or dose adjustment, repeated every 3 to 12
months as needed. Define responses to lifestyle and
statin therapy by percentage reductions in LDL-C
levels compared with baseline. In ASCVD patients at
very high-risk, triggers for adding nonstatin drug
therapy are defined by threshold LDL-C levels $70
mg/dL ($1.8 mmol/L) on maximal statin therapy   </s>