Table 1

Recommendations for statin initiation in primary prevention of cardiovascular diseases and goals of treatment, according to different guidelines

GuidelineScore for cardiovascular risk assessmentStatin eligibility and initial management*Goal of treatment
NICE (last update: 2016)2 QRISK2†Atorvastatin 20 mg per day if risk ≥10%↓ Non-HDL-c by 40%
ESC (2016)1 SCOREStatin considered or recommended as a function of cardiovascular risk and LDL-c levelVery high risk: LDL-c goal <1.8 mmol/L or ↓ LDL-c by ≥50% if baseline between 1.8 and 3.5 mmol/L
High risk: LDL-c goal <2.6 mmol/L or ↓ LDL-c by ≥50% if baseline between 2.6 and 5.2 mmol/L
Low or moderate risk: consider LDL-c goal <3.0 mmol/L
ACC/AHA/NLA/other (2018)3 Pooled cohort equationsStatin considered or recommended for individuals at borderline risk (5% to <7.5%), intermediate risk (≥7.5% to <20%), and high risk (≥20%)‡.
Risk-enhancing factors§ and coronary artery calcium score may help decision
If decided for statin in intermediate-risk or borderline-risk patients: start a moderate-intensity statin
Intermediate-risk: ↓ LDL-c by ≥30%
For optimal ASCVD risk reduction, especially in high-risk patients: ↓ LDL-c by ≥50%
Risk-enhancing factors favour intensification of statin therapy in intermediate-risk patients
  • *Decision on statin initiation should be preceded by a discussion with the patient on risks and benefits of the treatment.

  • †QRISK2 should not be used in individuals with an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2 and/or albuminuria.

  • ‡Recommendation for individuals aged 40–75 years, with LDL-c levels 1.7–4.8 mmol/L, without ASCVD or diabetes mellitus.

  • §Risk-enhancing factors include family history of premature ASCVD; primary hypercholesterolaemia (LDL-c 4.1–4.8 mmol/L, non–HDL-c 4.9–5.6 mmol/L); metabolic syndrome; chronic kidney disease; chronic inflammatory conditions; history of premature menopause (before 40 years) or pre-eclampsia; high-risk race/ethnicities; persistently elevated, primary hypertriglyceridaemia (≥1.98 mmol/L); high-sensitivity C reactive protein ≥2.0 mg/L; lipoprotein (a) ≥50 mg/dL or ≥125 nmol/L; apolipoprotein B ≥130 mg/dL; and ankle-brachial index <0.9.

  • ACC, American College of Cardiology; AHA, American Heart Association; ASCVD, atherosclerotic cardiovascular disease; ESC, European Society of Cardiology; HDL-c, high-density lipoprotein cholesterol; LDL-c, low-density lipoprotein cholesterol; NICE, National Institute for Health and Care Excellence; NLA, National Lipid Association; SCORE, Systemic Coronary Risk Estimation.