p.22 抽出テキスト
Circulation. 2019;139:e1082–e1143. DOI: 10.1161/CIR.0000000000000625 June 18/25, 2019 e1103 CLINICAL STATEMENTS AND GUIDELINES IIb B-R 8. In intermediate-risk adults who would benefit from more aggressive LDL-C lowering and in whom high-intensity statins are advisable but not acceptable or tolerated, it may be reasonable to add a nonstatin drug (ezetimibe or bile acid sequestrant) to a moderate-intensity statin.S4.4.2-9 IIb B-R 9. In patients at borderline risk, in risk discussion, the presence of risk-enhancing factors may justify initiation of moderateintensity statin therapy.S4.4.2-17,S4.4.2-24 *Definition of clinical ASCVD includes acute coronary syndrome (ACS), those with history of myocardial infarction (MI), stable or unstable angina or coronary or other arterial revascularization, stroke, transient ischemic attack (TIA), or peripheral artery disease (PAD) including aortic aneurysm, all of atherosclerotic origin. Synopsis Adults 40 to 75 years of age in primary prevention can be classified as borderline risk (10-year risk of ASCVD 5% to <7.5%), intermediate-risk (7.5% to <20%), and high-risk (20%). For intermediate-risk patients, moderate- to high-intensity statin therapy should be considered during risk discussion of treatment options. Additional considerations favoring use of statins in intermediate-risk patients include other independent risk conditions and, in selected individuals, risk-enhancing factors associated with greater ASCVD risk (Table 6). Although the variability of percent LDL-C lowering with high-intensity statin use is wide, its efficacy is proportional to the magnitude of the LDL-C reduction obtained.S4.4.2-18 Systematic reviews indicate that those with higher baseline ASCVD risk derive greater absolute benefit from higher percent LDL-C reduction with evidence-based therapy.S4.4.2-1,S4.4.2-7 Accordingly, if a statin is given, LDL-C levels should be reduced by ≥30% and optimally by ≥50%. When there is uncertainty, consideration of risk-enhancing factors including family history of premature ASCVD and CAC score, categorical risk factors, and selected biomarkers may inform the decision. CAC scoring is especially useful in older adults to improve specificity.S4.4.2-15 A CAC score of zero revises ASCVD risk downward and selects adults who show reduced benefit from starting a statin.S4.4.2-20 Recommendation-Specific Supportive Text 1. Prior guidelines recommended moderate- or highintensity statins as first-line LDL-C–lowering therapy in primary prevention of ASCVD after a risk discussion of treatment options. This was based on 3 large-scale exclusively primary-prevention RCTs that demonstrated that moderate-intensity statin therapyS4.4.2-5,S4.4.2-25 and high-intensity statin therapyS4.4.2-6 were associated with ASCVD risk reduction that outweighed the observable risks. Since those ACC/AHA 2013 guidelines, a largescale RCT in a racially/ethnically diverse population confirmed statin benefit from a moderate-intensity dose of a statin as compared with placebo in intermediate-risk patients. That RCT enrolled men ≥55 years of age and women ≥65 years of age with at least 1 cardiovascular risk factor. In the placebo group, the 10-year risk of “hard” ASCVD was 8.7%, and the risk of the expanded ASCVD endpoint that included coronary revascularization was 10%.S4.4.2-8 After 5.6 years, those assigned to rosuvastatin 10 mg/d demonstrated significant ARR in both co-primary endpoints with an acceptable safety record. By comparison, after a median follow-up of 1.9 years, those assigned a high-intensity dose of rosuvastatin in the JUPITER RCT achieved greater LDL-C-lowering and greater reductions in ASCVD outcomes. This corroborates meta-analyses demonstrating increased net benefit of evidence-based LDL-C–lowering therapy in those at risk if greater reductions in LDL-C are attained.S4.4.2-1,S4.4.2-9 2. If in the context of a risk discussion, maximal ASCVD risk reduction is desired, it is reasonable to use a high-intensity statin to lower LDL-C by ≥50%. This provides increased benefit, especially when 10-year ASCVD risk is ≥20%. JUPITER enrolled men ≥50 years of age and women 60 years of age with high-sensitivity C-reactive protein values 2.0 mg/L. Participants randomly assigned to 20 mg/d of rosuvastatin achieved median reductions in LDL-C of 50% and highly significant ASCVD risk reduction at 1.9 years.S4.4.2-6 The trial was stopped prematurely because of a highly significant reduction in cardiovascular death. However, wide individual variability in percent LDL-C reduction was noted. Importantly, the magnitude of the percent LDL-C reduction determined benefit.S4.4.2-18 The US Preventive Services Task Force systematic review of statin therapy in primary prevention showed a reduced risk of all-cause and cardiovascular death and ASCVD events and noted greater absolute benefits in those at greater baseline risk,S4.4.2-4 consistent with other high-quality systematic reviews and meta-analyses.S4.4.2-1,S4.4.2-7,S4.4.2-24 This underscores the need for aggressive and safe risk reduction in the highest-risk groups and the need for followup LDL-C testing to determine adherence and adequacy of effect of the prescribed statin.S4.4.2-26 3. In individuals 40 to 75 years of age, 10-year ASCVD risk assessment begins the clinician–patient risk Primary Prevention Recommendations for Adults 40 to 75 Years of Age With LDL Levels 70 to 189 mg/dL (1.7 to 4.8 mmol/L) (Continued) COR LOE Recommendations Downloaded from http://ahajournals.org by on October 7, 2026