The Lipid Guideline I Follow in Primary Care

Kenneth W. Lin, MD, MPH


September 25, 2020

Editorial Collaboration

Medscape &

Hi, everyone. I'm Dr Kenny Lin. I am a family physician at Georgetown University Medical Center, and I blog at Common Sense Family Doctor.

We now have three cholesterol management guidelines produced by three well-respected organizations, all applicable to primary care practice. If family physicians are confused, it's with good reason. (Read on for my choice.)

Which Guideline to Follow?

American College of Cardiology/American Heart Association (ACC/AHA). A couple of years ago, I gave a mostly positive review on Medscape of the 2018 cholesterol management guideline. Although it was an improvement over the ACC/AHA's previous guideline in that it eliminated financial conflicts of interest and placed more emphasis on shared decision-making surrounding starting a statin, the American Academy of Family Physicians assigned it an Affirmation of Value (a qualified endorsement) because of concern that "many recommendations were based on low-quality or insufficient evidence such as those addressing specific [low-density lipoprotein] target levels for treatment and the use of coronary artery calcium (CAC) scoring for decision-making."

US Preventive Services Task Force (USPSTF). The USPSTF's current recommendations are its 2016 recommendation statement on statin use for the primary prevention of cardiovascular disease (CVD) in adults. The USPSTF recently posted a draft research plan to update that statement, but it probably will not become official until 2022.

US Departments of Veterans Affairs and Defense (VA/DoD). VA/DoD has just released its own clinical practice guideline on management of dyslipidemia for CVD risk reduction. (A synopsis was published in Annals of Internal Medicine.) Unlike the ACC/AHA guideline, the VA/DoD systematically reviewed the evidence for 12 key questions, identifying 141 studies that supported 27 separate clinical recommendations.

The main principles of the VA/DoD dyslipidemia guideline echo those of the ACC/AHA's and USPSTF's versions:

  • Assess 10-year CVD event risk in adults starting at age 40

  • Choose a statin for primary prevention

  • Intensify therapy in patients with higher-risk CVD

  • Recommend a Mediterranean diet, regular aerobic exercise, and smoking cessation

However, the VA/DoD diverges from the ACC/AHA in recommending fixed moderate-intensity statin doses used in randomized trials rather than aiming for target LDL levels. The VA/DoD also suggests not using CAC scoring to refine risk prediction, due to high cost, radiation exposure, and insufficient evidence that it improves outcomes. And although the guideline recommends repeating CVD risk evaluations every 2 or 5 years depending on the initial risk estimate, it somewhat surprisingly suggests measuring nonfasting lipid levels only once every 10 years, based on evidence that these remain relatively stable over time and contribute minimally to predicted risk.

And the Winner Is...

Until the USPSTF updates its 2016 recommendation statement, I advise mostly relying on the VA/DoD's guidance, particularly for primary prevention. By performing a more comprehensive systematic review of the key clinical questions and not making any recommendations that go beyond the supporting evidence, the VA/DoD ensured that its guideline is the most likely to improve patient outcomes and minimize harms.

Kenny Lin, MD, MPH, teaches family medicine, preventive medicine, and health policy at Georgetown University School of Medicine. He is deputy editor of the journal American Family Physician.

Follow Medscape on Facebook, Twitter, Instagram, and YouTube


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.