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2013 ACC/AHA
Blood Cholesterol Treatment
Guidelines
“Intensity Of Statin Therapy”
Aim to Reduce RISK … not at Target levels
DR.PRAVEEN NAGULA
Scope of guideline
• to reduce atherosclerotic cardiovascular disease(ASCVD)risk
{RCTs,systematic analysis and metaanalysis of RCTs}.
• ASCVD – coronary heart disease(CHD),stroke,and
peripheral arterial disease,all of presumed atherosclerotic
origin.
• to provide strong evidence-based foundation.
• only evidence from statin RCTs were used to develop
guidelines.****
• Comprehensive approach to lipid management for purposes
with relation to ASCVD reduction only,not for complex lipid
disorders.
What do present guidelines say.....
Patient centered approach
rather than
one treatment fits all
What’s new in the guideline…?
2013 ACC/AHA guidelines for blood cholesterol management
Benefits of Statins
• High intensity therapy – lowering LDL cholesterol by >50%.
• Moderate intensity therapy - lowering LDL cholesterol by 30-50%.
• Reduces ASCVD events across the spectrum of baseline LDL-C
levels > 70 mg/dl.
• Relative reduction in ASCVD risk is consistent for primary and
secondary prevention.
 Absolute reduction in ASCVD events is proportional to baseline
absolute ASCVD risk.
 Statin therapy only for individuals at increased ASCVD risk .
Who are to be benefited
by Statins ?????
2013 ACC/AHA guidelines for blood cholesterol management
2013 ACC/AHA guidelines for blood cholesterol management
Primary prevention of ASCVD
• Based on the estimated absolute 10 yr risk of ASCVD
(non fatal MI,CHD death,nonfatal and fatal stroke)…
• The omnibus CV risk calculator for
 Pts without clinical ASCVD and LDL 70-189mg/dl
Estimates 10 yr risk of ASCVD
 In diabetics ,for primary prevention
Not in pts with clinical ASCVD
2013 ACC/AHA guidelines for blood cholesterol management
Statin treatment:Recommendations
2013 ACC/AHA guidelines for blood cholesterol management
2013 ACC/AHA guidelines for blood cholesterol management
Primary prevention in patients with
LDL>190mg/dl
LDL-C
>190mg/dl

Age>21 years

Evaluate for cause

Management

primary

secondary

High dose
statin

Maximum
tolerated
dose

LDL-C
reduction of
atleast 50%

IB

IB

IIaB

Evaluate
and treat
accordingly
Primary prevention in patients with
diabetes
LDLcholesterol
70-189 mg/dl

Diabetes
Age
Statins

40-75 yrs

<40 yrs,
>75yrs

Moderate
intensity
statins

High intensity
statins
with risk >7.5%

Balance between
ASCVDbenefits and
adverse effects

IA

IIa B

IIa C
Patients without
diabetes,primary
prevention

LDLcholesterol
70-189 mg/dl

>7.5
%

10 yr ASCVD
risk estimate
Age of the patient

40-75 yrs

Moderate to
high intensity
therapy

IA

5-7.5%
>75
yrs
Assess
risk,
benefits

40-75
yrs
Moderate
intensity
therapy

IIa B

>75
yrs
Assess
risks
benefits
Statins in Heart Failure,
Hemodialysis patients
LDL
cholesterol
>190
mg/dl
Pt had CAD,
HTN,smoker,
not on statins

Age 45
yrs

Age 75
yrs

Start Statins
to the
maximum
tolerated
dose

Pt
diabetic,no
CAD,
ASCVDrisk
>7.5%

Assess
risk,benefits

High
intensity
statins

70-189
mg/dl
Pt not
diabetic,
noCAD

Pt CAD

Evaluate
secondary
causes

Statins

High dose
statin
therapy

Pt
diabetic

Moderat
dose
statins

Pt no
h/o
CAD,
DM2,
risk
<7.5%

Assess
risk,
benefits

Pt having
CKD

No EBT
for
statins
High- Moderate – and Low –
Intensity Statin Therapy
Clinical application by Statin dose
STATINS
HIGH INTENSITY
THERAPY

MODERATE
INTENSITY THERAPY

Daily dose lowers LDL-C
on average,by
approximately ≥50%

Daily dose lowers LDL –C Daily dose lowers LDL –C
on average,by
<30%
approximately 30-50%

Atorvastatin (40) 80 mg

Atorvastatin 10 (20) mg

Simvastatin 10 mg

Rosuvastatin 20 (40) mg

Rosuvastatin (5) 10 mg

Pravastatin 10-20 mg

Simvastatin 20-40 mg

Lovastatin 20 mg

Pravastatin 40 (80) mg

Fluvastatin 20-40 mg

Lovastatin 40 mg

Pitavastatin 1 mg

Fluvastatin XL 80 mg
Fluvastatin 40 mg bid
Pitavastatin 2-4 mg

LOW INTENSITY
THERAPY
Safety recommendations of statins
NHLBI ACC/AHA
COR
1.Creatine Kinase,routinely not needed
A
III no benefiit
2.Baseline CK in pts at risk of events

E

3.Baseline ALT before initiating statins

LOE
A

B

IIa
I

C
B

4.Decreasing the statin dose,if 2
consecutive values of LDL-C <40
mg/dl.

C

IIb

C

5.Simvastatin at 80 mg daily harmful

B

6.New onset diabetes on statin
therapy,continue statins

B

III harm
I

A
B

7.If muscle symtpoms
develop,discontinue,use again

E

II a

C

8.Confusional state,see secondary
causes

E

II b

C
Monitoring statin
treatment
What do guidelines say..
2013 ACC/AHA guidelines for blood cholesterol management
Lifestyle is

the foundation
for
ASCVD risk reduction

 Adhering to a healthy heart diet,
 Regular exercise habits
 Avoidance of tobacco products
 Maintenance of healthy weight

• Remains critical component both prior to and in
concert with the use of cholesterol lowering drug
therapies
What is the fate of
nonstatins in guidelines
are they Ignored??
Niacin

Niacin

Baseline hepatic
transaminases,FBS,HBA1c

Start at low dose

Hepatic transaminases
elevations are higher
>2-3ULN

Take niacin with food
or aspirin

Persistent severe cutaneous
symptoms,hyperglycemia,
acute gout

500 mg ER to
2000mgER

New onset AF,

weight loss
Bile acid
sequestrants
Baseline TG
>300 mg/dl

250-299 mg/dl

Cholesterol
absorption
inhibitors
Baseline hepatic
transaminases

Discontinue if
ALT>3 times
occur

Fibrates
IA
IIa/IIbB
III

Omega 3 fatty acids

Gemfibrozil in patients
on statin therapy

Severe
hypertriglyceridemia

If TG>500mg/dl and
benefit>risks

Evaluate GI
disturbances

GFR<30 ml/min
Secondary causes of hyperlipidemia
Secondary cause

Elevated LDL - C

ELEVATED TRIGLYCERIDES

DIET

Saturated or trans fats,
wt gain,anorexia

Wt gain,
very low fat diets, high intake
of refined carbohydrates,
excessive alcohol intake

DISEASES

Biliary obstruction ,
nephrotic syndrome

Nephrotic syndrome, CKD,
lipodystrophies

DRUGS

Duiretics,cyclosporine,
glucocorticoids,amiodarone

Oral
estrogens,glucocorticoids,
bile acid sequestrants
protease inhibitors,
retinoic acid,sirolimus,
beta blockers,thiazides

ALTERED
METABOLISM

Hypothyroidism,
Obesity,pregnancy

Diabetes, hypothyroidism,
obesity, pregnancy

Statins,niacin,ezetimbe
C/I in pregnancy,lactation
2013 ACC/AHA guidelines for blood cholesterol management
Evolution of guidelines
NCEP
ATP I
1988

NCEP
ATPIII
2001

NCEP
ATP II
1993

NCEP
ATP IV
2013??

NCEP
ATP III
REVISED
2004

ACC/AHA
2013
2013 ACC/AHA guidelines for blood cholesterol management
2013 ACC/AHA guidelines for blood cholesterol management
2013 ACC/AHA guidelines for blood cholesterol management
2013 ACC/AHA guidelines for blood cholesterol management
Basis for the New Guidelines
 RCTs reviewed showed a consistent reduction in ASCVD
events from Statins therapy in secondary and primary
prevention, no ASCVD event reduction in those with NYHA
class II-IV HF or receiving maintenance hemodialysis.
 Only fixed doses of statins with placebo or untreated
controls,comparison of high dose with moderate intensity
statins.
 No evaluation of the effect of titrated (dose adjusted) statin
treatment to achieve prespecified LDL- C or non HDL-C
goals.
 Use of niacin to additionally lower non HDL –C,once an LDL
target was achieved,did not further reduce ASCVD
outcomes.(AIM HIGH trial)
 The intensity of statin therapy is appropriate on those most
likely to benefit.
3 CQs –
CQ1 secondary,(19RCT)
CQ2 – primary
prevention (6RCT)
CQ3 – comprehensive
management,safety of
each drug

•
•
•

Rosuvastatin to prevent vascular events in men and women with elevated C-reactive protein. N Engl J Med 2008;359:2195-207
AFCAPS-TEXCAPS, JAMA 1998;279:1615–1622
MEGA trial, Lancet 2006;368:1155–1163.
Why other approaches
ignored???
 1.Treat to Target – widely used for past 15 yrs
What is the target ?
What is the additional risk reduction beyond one target lower
than other?
adverse effects from multidrug therapy that occur in achieving
goal
undertreatment with statins, overtreatment with nonstatins
 2.lowest is best
adverse effects?
 3.lifetime risk
long term follow up >15 yrs?
statins>10yrs?
Why Target level therapy
ignored..how came the picture of
statin benefit groups?
Hypothesis or Evidence based..
Myth or reality
A.Secondary Prevention
 Evidence – high intenisty therapy to maximally lower LDL –C than
using a target.
 Ex – LDL –C 78mg/dl on a dose of atorvas 80 mg/dl –receiving EBT.
 No data to show that adding a nonstatin drug to high intenisty statin
therapy will provide incremental ASCVD risk reduction benefit with
acceptable margin of safety.(AIM HIGH,ACCORD).
 This patient may be exposed to adverse effects if started of a drug with
no evidence of benefit,just because his LDLis more than arbitrarily
level.
 This is treated as a case of failure..for a lag of 8 mg/dl..Is it justifiable
???

AIM HIGH trial NewEngl J Med 2011;365:2255-67
ACCORD, N Engl J Med 2010;362:1563–74

.
B.FH with LDL –C >190 mg/dl
 many does not achieve <100mg/dl.
 maximum may be 120 mg/dl on 3 drugs.
 These pts may have fallen short of target ,but their LDL –C
>50% ,more ASCVD risk reduction.
 Not treatment failures.
C.Type2Diabetes :
 have lower LDL-C than with without diabetes.
 goal directed therapy encourages low statin doses,use of drugs
for addressing HDL-C/high TG.
 maximally tolerated therapy to be given primary importance.
D.Estimated ASCVD >7.5%
Cholesterol Treatment Trialists Collaboration, Lancet 2012;380:581–90.
Taylor F, Ward K, Moore TH et al. 2011:CD004816
Limitations
• Clinical judgement required in pts,for whom RCT evidence is
insufficient
• Younger adults< 40 yrs with <7.5% ASCVD risk for 10
yrs,high lifetime risk.
• HIV pts,rheumatological pts,IBD pts.
• RCTS,Systematic reviews,meta analysis of RCTs were taken
into consideration.
New Drugs
• Cholesterol ester transfer protein (CETP) inhibitors -

Anacetrapib(DEFINE,REVEAL), dalcetrapib
• Ab to pro-protein convertase subtilisin/kexin 9 (PCSK9).

• Apolipoprotein B synthesis inhibitors - Mipomersen
• Microsomal triglyceride transfer protein (MTP) inhibitors,

• Thyroid hormone analogue Eprotirome
Future..
 Primary prevention in >75 yrs age
 Alternate treatment strategies.
 Effectiveness of submaximal doses of statins vs nonstatins in
intolerant pts
 Evaluation of the incidence of new onset diabetes associated
with statin therapy.
 Outcomes of RCTs of new lipid modifying agents to determine
the incremental ASCVD reduction when added to statin
therapy.
Future updates required for..
 1.The treatment of Hypertriglyceridemia.
 2.Use of NonHDL-C in decision making.
 3.Whether on-treatment markers such as
apoB,Lp(a),LDLparticles are useful in guiding decisions.
 4.Best approaches to use noninvasive imaging for refining
risk estimates to guide treatment.
 5.Optimal age for starting treatment for reducing lifetime risk
of ASCVD.
 6.What to do in pts with HF,hemodialysis.
 7.Long term effects of statin associated new onset diabetes and
management.
Conclusions
 Patient centered approach is to be given importance rather than
one treatment fits all concept.
 Statins to be given at high intenisty,moderate intensity doses but not
with target levels of attainment.
 Nonstatins give no ASCVD benefit in pts with high intensity statin
therapy.
 Use of lipoprotein a ,non HDLcholesterol levels assessment is not
recommended.
 Pts without ASCVD should be started of the statins after assessing 10 yr
risk by omnibus calculators.
 New onset diabetes due to statins needs further assessment in future.
 New drugs in pipeline,RCT s required for their incremental benefit in
ASCVD risk reduction when added to statins
 Lifestyle modification remains the key concept of the management of
blood cholesterol.
2013 ACC/AHA guidelines for blood cholesterol management

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2013 ACC/AHA guidelines for blood cholesterol management

  • 1. 2013 ACC/AHA Blood Cholesterol Treatment Guidelines “Intensity Of Statin Therapy” Aim to Reduce RISK … not at Target levels
  • 3. Scope of guideline • to reduce atherosclerotic cardiovascular disease(ASCVD)risk {RCTs,systematic analysis and metaanalysis of RCTs}. • ASCVD – coronary heart disease(CHD),stroke,and peripheral arterial disease,all of presumed atherosclerotic origin. • to provide strong evidence-based foundation. • only evidence from statin RCTs were used to develop guidelines.**** • Comprehensive approach to lipid management for purposes with relation to ASCVD reduction only,not for complex lipid disorders.
  • 4. What do present guidelines say.....
  • 5. Patient centered approach rather than one treatment fits all
  • 6. What’s new in the guideline…?
  • 8. Benefits of Statins • High intensity therapy – lowering LDL cholesterol by >50%. • Moderate intensity therapy - lowering LDL cholesterol by 30-50%. • Reduces ASCVD events across the spectrum of baseline LDL-C levels > 70 mg/dl. • Relative reduction in ASCVD risk is consistent for primary and secondary prevention.  Absolute reduction in ASCVD events is proportional to baseline absolute ASCVD risk.  Statin therapy only for individuals at increased ASCVD risk .
  • 9. Who are to be benefited by Statins ?????
  • 12. Primary prevention of ASCVD • Based on the estimated absolute 10 yr risk of ASCVD (non fatal MI,CHD death,nonfatal and fatal stroke)… • The omnibus CV risk calculator for  Pts without clinical ASCVD and LDL 70-189mg/dl Estimates 10 yr risk of ASCVD  In diabetics ,for primary prevention Not in pts with clinical ASCVD
  • 17. Primary prevention in patients with LDL>190mg/dl LDL-C >190mg/dl Age>21 years Evaluate for cause Management primary secondary High dose statin Maximum tolerated dose LDL-C reduction of atleast 50% IB IB IIaB Evaluate and treat accordingly
  • 18. Primary prevention in patients with diabetes LDLcholesterol 70-189 mg/dl Diabetes Age Statins 40-75 yrs <40 yrs, >75yrs Moderate intensity statins High intensity statins with risk >7.5% Balance between ASCVDbenefits and adverse effects IA IIa B IIa C
  • 19. Patients without diabetes,primary prevention LDLcholesterol 70-189 mg/dl >7.5 % 10 yr ASCVD risk estimate Age of the patient 40-75 yrs Moderate to high intensity therapy IA 5-7.5% >75 yrs Assess risk, benefits 40-75 yrs Moderate intensity therapy IIa B >75 yrs Assess risks benefits
  • 20. Statins in Heart Failure, Hemodialysis patients
  • 21. LDL cholesterol >190 mg/dl Pt had CAD, HTN,smoker, not on statins Age 45 yrs Age 75 yrs Start Statins to the maximum tolerated dose Pt diabetic,no CAD, ASCVDrisk >7.5% Assess risk,benefits High intensity statins 70-189 mg/dl Pt not diabetic, noCAD Pt CAD Evaluate secondary causes Statins High dose statin therapy Pt diabetic Moderat dose statins Pt no h/o CAD, DM2, risk <7.5% Assess risk, benefits Pt having CKD No EBT for statins
  • 22. High- Moderate – and Low – Intensity Statin Therapy Clinical application by Statin dose
  • 23. STATINS HIGH INTENSITY THERAPY MODERATE INTENSITY THERAPY Daily dose lowers LDL-C on average,by approximately ≥50% Daily dose lowers LDL –C Daily dose lowers LDL –C on average,by <30% approximately 30-50% Atorvastatin (40) 80 mg Atorvastatin 10 (20) mg Simvastatin 10 mg Rosuvastatin 20 (40) mg Rosuvastatin (5) 10 mg Pravastatin 10-20 mg Simvastatin 20-40 mg Lovastatin 20 mg Pravastatin 40 (80) mg Fluvastatin 20-40 mg Lovastatin 40 mg Pitavastatin 1 mg Fluvastatin XL 80 mg Fluvastatin 40 mg bid Pitavastatin 2-4 mg LOW INTENSITY THERAPY
  • 24. Safety recommendations of statins NHLBI ACC/AHA COR 1.Creatine Kinase,routinely not needed A III no benefiit 2.Baseline CK in pts at risk of events E 3.Baseline ALT before initiating statins LOE A B IIa I C B 4.Decreasing the statin dose,if 2 consecutive values of LDL-C <40 mg/dl. C IIb C 5.Simvastatin at 80 mg daily harmful B 6.New onset diabetes on statin therapy,continue statins B III harm I A B 7.If muscle symtpoms develop,discontinue,use again E II a C 8.Confusional state,see secondary causes E II b C
  • 27. Lifestyle is the foundation for ASCVD risk reduction  Adhering to a healthy heart diet,  Regular exercise habits  Avoidance of tobacco products  Maintenance of healthy weight • Remains critical component both prior to and in concert with the use of cholesterol lowering drug therapies
  • 28. What is the fate of nonstatins in guidelines are they Ignored??
  • 29. Niacin Niacin Baseline hepatic transaminases,FBS,HBA1c Start at low dose Hepatic transaminases elevations are higher >2-3ULN Take niacin with food or aspirin Persistent severe cutaneous symptoms,hyperglycemia, acute gout 500 mg ER to 2000mgER New onset AF, weight loss
  • 30. Bile acid sequestrants Baseline TG >300 mg/dl 250-299 mg/dl Cholesterol absorption inhibitors Baseline hepatic transaminases Discontinue if ALT>3 times occur Fibrates IA IIa/IIbB III Omega 3 fatty acids Gemfibrozil in patients on statin therapy Severe hypertriglyceridemia If TG>500mg/dl and benefit>risks Evaluate GI disturbances GFR<30 ml/min
  • 31. Secondary causes of hyperlipidemia Secondary cause Elevated LDL - C ELEVATED TRIGLYCERIDES DIET Saturated or trans fats, wt gain,anorexia Wt gain, very low fat diets, high intake of refined carbohydrates, excessive alcohol intake DISEASES Biliary obstruction , nephrotic syndrome Nephrotic syndrome, CKD, lipodystrophies DRUGS Duiretics,cyclosporine, glucocorticoids,amiodarone Oral estrogens,glucocorticoids, bile acid sequestrants protease inhibitors, retinoic acid,sirolimus, beta blockers,thiazides ALTERED METABOLISM Hypothyroidism, Obesity,pregnancy Diabetes, hypothyroidism, obesity, pregnancy Statins,niacin,ezetimbe C/I in pregnancy,lactation
  • 33. Evolution of guidelines NCEP ATP I 1988 NCEP ATPIII 2001 NCEP ATP II 1993 NCEP ATP IV 2013?? NCEP ATP III REVISED 2004 ACC/AHA 2013
  • 38. Basis for the New Guidelines
  • 39.  RCTs reviewed showed a consistent reduction in ASCVD events from Statins therapy in secondary and primary prevention, no ASCVD event reduction in those with NYHA class II-IV HF or receiving maintenance hemodialysis.  Only fixed doses of statins with placebo or untreated controls,comparison of high dose with moderate intensity statins.  No evaluation of the effect of titrated (dose adjusted) statin treatment to achieve prespecified LDL- C or non HDL-C goals.  Use of niacin to additionally lower non HDL –C,once an LDL target was achieved,did not further reduce ASCVD outcomes.(AIM HIGH trial)  The intensity of statin therapy is appropriate on those most likely to benefit.
  • 40. 3 CQs – CQ1 secondary,(19RCT) CQ2 – primary prevention (6RCT) CQ3 – comprehensive management,safety of each drug • • • Rosuvastatin to prevent vascular events in men and women with elevated C-reactive protein. N Engl J Med 2008;359:2195-207 AFCAPS-TEXCAPS, JAMA 1998;279:1615–1622 MEGA trial, Lancet 2006;368:1155–1163.
  • 42.  1.Treat to Target – widely used for past 15 yrs What is the target ? What is the additional risk reduction beyond one target lower than other? adverse effects from multidrug therapy that occur in achieving goal undertreatment with statins, overtreatment with nonstatins  2.lowest is best adverse effects?  3.lifetime risk long term follow up >15 yrs? statins>10yrs?
  • 43. Why Target level therapy ignored..how came the picture of statin benefit groups? Hypothesis or Evidence based.. Myth or reality
  • 44. A.Secondary Prevention  Evidence – high intenisty therapy to maximally lower LDL –C than using a target.  Ex – LDL –C 78mg/dl on a dose of atorvas 80 mg/dl –receiving EBT.  No data to show that adding a nonstatin drug to high intenisty statin therapy will provide incremental ASCVD risk reduction benefit with acceptable margin of safety.(AIM HIGH,ACCORD).  This patient may be exposed to adverse effects if started of a drug with no evidence of benefit,just because his LDLis more than arbitrarily level.  This is treated as a case of failure..for a lag of 8 mg/dl..Is it justifiable ??? AIM HIGH trial NewEngl J Med 2011;365:2255-67 ACCORD, N Engl J Med 2010;362:1563–74 .
  • 45. B.FH with LDL –C >190 mg/dl  many does not achieve <100mg/dl.  maximum may be 120 mg/dl on 3 drugs.  These pts may have fallen short of target ,but their LDL –C >50% ,more ASCVD risk reduction.  Not treatment failures. C.Type2Diabetes :  have lower LDL-C than with without diabetes.  goal directed therapy encourages low statin doses,use of drugs for addressing HDL-C/high TG.  maximally tolerated therapy to be given primary importance. D.Estimated ASCVD >7.5% Cholesterol Treatment Trialists Collaboration, Lancet 2012;380:581–90. Taylor F, Ward K, Moore TH et al. 2011:CD004816
  • 46. Limitations • Clinical judgement required in pts,for whom RCT evidence is insufficient • Younger adults< 40 yrs with <7.5% ASCVD risk for 10 yrs,high lifetime risk. • HIV pts,rheumatological pts,IBD pts. • RCTS,Systematic reviews,meta analysis of RCTs were taken into consideration.
  • 47. New Drugs • Cholesterol ester transfer protein (CETP) inhibitors - Anacetrapib(DEFINE,REVEAL), dalcetrapib • Ab to pro-protein convertase subtilisin/kexin 9 (PCSK9). • Apolipoprotein B synthesis inhibitors - Mipomersen • Microsomal triglyceride transfer protein (MTP) inhibitors, • Thyroid hormone analogue Eprotirome
  • 48. Future..  Primary prevention in >75 yrs age  Alternate treatment strategies.  Effectiveness of submaximal doses of statins vs nonstatins in intolerant pts  Evaluation of the incidence of new onset diabetes associated with statin therapy.  Outcomes of RCTs of new lipid modifying agents to determine the incremental ASCVD reduction when added to statin therapy.
  • 49. Future updates required for..  1.The treatment of Hypertriglyceridemia.  2.Use of NonHDL-C in decision making.  3.Whether on-treatment markers such as apoB,Lp(a),LDLparticles are useful in guiding decisions.  4.Best approaches to use noninvasive imaging for refining risk estimates to guide treatment.  5.Optimal age for starting treatment for reducing lifetime risk of ASCVD.  6.What to do in pts with HF,hemodialysis.  7.Long term effects of statin associated new onset diabetes and management.
  • 50. Conclusions  Patient centered approach is to be given importance rather than one treatment fits all concept.  Statins to be given at high intenisty,moderate intensity doses but not with target levels of attainment.  Nonstatins give no ASCVD benefit in pts with high intensity statin therapy.  Use of lipoprotein a ,non HDLcholesterol levels assessment is not recommended.  Pts without ASCVD should be started of the statins after assessing 10 yr risk by omnibus calculators.  New onset diabetes due to statins needs further assessment in future.  New drugs in pipeline,RCT s required for their incremental benefit in ASCVD risk reduction when added to statins  Lifestyle modification remains the key concept of the management of blood cholesterol.