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ACP develops three different types of clinical recommendations:

Clinical Practice Guidelines, Clinical Guidance Statements, and Best Practice Advice. ACP's goal is to provide clinicians with recommendations based on the best available evidence; to inform clinicians of when there is no evidence; and finally, to help clinicians deliver the best health care possible.

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Our goal is to help clinicians deliver the best health care possible.

The American College of Physicians (ACP) established its evidence-based clinical practice guidelines program in 1981. The ACP clinical practice guidelines and guidance statements follow a multistep development process that includes a systematic review of the evidence, deliberation of the evidence by the committee, summary recommendations, and evidence and recommendation grading.

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A 58-year-old man is evaluated during a routine appointment. He is asymptomatic. He was diagnosed with type 2 diabetes mellitus 4 years ago and has hypertension, dyslipidemia, and obesity. His medications are enteric-coated low-dose aspirin, lisinopril, fluvastatin (20 mg/d), and metformin.

His calculated 10-year risk of atherosclerotic cardiovascular disease (ASCVD) using the Pooled Cohort Equations is 10%.

On physical examination, blood pressure is 126/78 mm Hg and pulse rate is 72/min. The remainder of the examination is normal.

Laboratory studies:

Total cholesterol

186 mg/dL (4.82 mmol/L)

LDL cholesterol

123 mg/dL (3.19 mmol/L)

HDL cholesterol

44 mg/dL (1.14 mmol/L)


109 mg/dL (1.23 mmol/L)


Which of the following is the most appropriate statin management?

The most appropriate management in this patient with a coronary heart disease (CHD) risk equivalent is to switch to atorvastatin, 40 mg/d. Current guidelines recommend that statin therapy be initiated in patients at high risk for CHD. The intensity of the statin therapy should be tailored to the CHD risk. Candidates for high-intensity statin therapy include:

  • Patients with known atherosclerotic disease (clinical CHD, cerebrovascular disease, or peripheral arterial disease)
  • Patients with an LDL cholesterol level 190 mg/dL (4.92 mmol/L) or greater
  • Patients with diabetes mellitus, an LDL cholesterol level below 190 mg/dL (4.92 mmol/L), and calculated 10-year CHD risk of 7.5% or higher
  • Some patients without diabetes with an LDL cholesterol level below 190 mg/dL (4.92 mmol/L) and calculated 10-year CHD risk of 7.5% or higher

Moderate-intensity statin therapy can be considered for:

  • Patients with diabetes who are not receiving high-intensity therapy
  • Most patients without diabetes with an LDL cholesterol level below 190 mg/dL (4.92 mmol/L) and calculated 10-year CHD risk of 7.5% or higher
  • Some patients without diabetes with an LDL cholesterol level below 190 mg/dL (4.92 mmol/L) and calculated 10-year CHD risk of 5% or higher but lower than 7.5%

This patient has diabetes, an LDL cholesterol level less than 190 mg/dL (4.92 mmol/L), and a calculated 10-year CHD of 10%, and, therefore, should be considered for high-intensity statin therapy. Drugs and doses that constitute high-intensity statin therapy include atorvastatin, 40 to 80 mg/d; rosuvastatin, 20 to 40 mg/d; and simvastatin, 80 mg/d. (The FDA has issued a warning regarding the incidence of muscle injury with products that contain 80 mg of simvastatin and recommends that patients be switched to a different statin rather than increasing the dosage of simvastatin to 80 mg/d.)

Fluvastatin, 40 mg/d; lovastatin, 20 mg/d; pravastatin, 10 mg/d; and simvastatin, 10 mg/d, are all classified as low-intensity dosing and are inadequate to reduce this patient's CHD risk.

Key Point

  • Patients with diabetes mellitus should receive moderate- or high-intensity statin therapy to reduce their risk of coronary heart disease.
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