3.3.3.0 Pri­ma­ry Pre­ven­tion (Pa­tients With­out ASCVD)

3.3.3.1 Pri­ma­ry Pre­ven­tion (Pa­tients With­out ASCVD)

For pri­ma­ry pre­ven­tion, mod­er­ate-‍dose statin ther­a­py is rec­om­mend­ed for those 40 years and older (80,87,88), though high-‍in­ten­si­ty ther­a­py may be con­sid­ered on an in­di­vid­u­al basis in the con­text of ad­di­tional ASCVD risk fac­tors. The ev­i­dence is strong for pa­tients with di­a­betes aged 40–75 years, an age-‍group well repre­sent­ed in statin tri­als show­ing benefit. Since risk is en­hanced in pa­tients with di­a­betes, as noted above, pa­tients who also have mul­ti­ple other coro­nary risk fac­tors have in­creased risk, equiv­a­lent to that of those with ASCVD. As such, re­cent guide­lines rec­om­mend that in pa­tients with di­a­betes who have mul­ti­ple ASCVD risk fac­tors, it is rea­son­able to pre­scribe high-‍in­ten­si­ty statin ther­a­py (12,89). Fur­ther­more, for pa­tients with di­a­betes whose ASCVD risk is >20%, i.e., an ASCVD risk equiv­a­lent, the same high-‍in­ten­si­ty statin ther­a­py is rec­om­mend­ed as ­for those­with­ doc­u­ment­ed ASCVD (12). The ev­i­dence is lower for pa­tients aged >75 years; rel­a­tively few older pa­tients with di­a­betes have been en­rolled in pri­ma­ry pre­ven­tion tri­als. How­ev­er, het­ero­gene­ity by age has not been seen in the rel­a­tive benefit of lipid-‍low­er­ing ther­a­py in tri­als that in­cluded older par­tic­i­pants (78,85,86), and be­cause older age con­fers high­er risk, the ab­so­lute benefits are ac­tu­al­ly greater (78,90). Moderate-in­ten­si­ty statin ther­a­py is rec­om­mend­ed in pa­tients with di­a­betes that are 75 years or older. How­ev­er, the risk-‍benefit profile should be rou­tinely eval­u­ated in this pop­u­la­tion, with down­ward titra­tion of dose per­formed as need­ed. See Sec­tion 12 “Older Adults” for more de­tails on clin­i­cal con­sid­erations for this pop­u­la­tion.