In the new guidelines, statin treatment targets are back for both primary and secondary prevention. Patients whose 10-year risk of ASCVD is 20% or more should try to reduce LDL-C levels by at least 50%, the same goal as for people with clinical ASCVD. Those with more intermediate risk should aim for at least a 30% decrease.

The new update was met with considerably less controversy than the last incarnation, which deemphasized LDL-C treatment targets and introduced the AHA/ACC ASCVD risk calculator.

The updated guidelines and a companion AHA/ACC special report on risk assessment tools acknowledge that the calculator estimates risk for an average person in the US population and may overestimate—or underestimate—a given person’s chances of having an ASCVD event within 10 years.

Researchers presented at least 2 alternate calculators, including 1 using machine learningthat more accurately estimated risk in a specific cohort than did the ACC’s calculator. A recent report in JAMA Cardiology also found that using long-term cumulative systolic blood pressure instead of single blood pressure measurements could make the pooled cohort equations more accurate.

Another new feature of the guidelines is that clinicians are now encouraged to have a comprehensive risk discussion with patients before initiating statin therapy, which should include a consideration of potential adverse effects and drug interactions, costs, and patient preferences and values. “The guideline places importance on a process of shared decision-making,”

Greenland emphasized that no risk calculator is perfect: “Doctors have hunches about patients based on a variety of clinical factors, and what these calculators are intended to do is to make your hunch a little more accurate,” he said. For now, the guidelines reaffirm the use of the pooled cohort equations for the US population, and state that they should be used as a “starting point, not as the final arbiter, for decision-making in primary prevention of ASCVD.”

Meanwhile, a new AHA scientific statement released in December may help quell patient fears about statins. The report found that statin-related muscle aches and pains, the drugs’ most common adverse effects, occur in no more than 1% of patients. The statement concluded that statins have a low risk of adverse effects and that, for most people, their benefits outweigh the risks.