The International Atherosclerosis Society (IAS) has updated its recommendations on treatment of high level of blood cholesterol and dyslipidemia for the purpose of reducing risk for atherosclerotic cardiovascular disease (ASCVD).

The writing panel reviewed existing evidence-based recommendations and consolidated them into an overall set of recommendations, which are meant to inform clinical judgment and not to replace it.

The major innovations in the Position Paper are:

• International consensus guidelines based on multiple lines of evidence.
• Identification of non-HDL-cholesterol (non-HDL-C) as a major form of atherogenic cholesterol.
• Definition of atherogenic cholesterol as either LDL-cholesterol (LDL-C) or non-HDL-C.
• Definition of optimal levels of atherogenic cholesterol (both LDL-C and non-HDL-C) for primary and secondary prevention.
• Assigning priority to long-term risk categories over short-term risk.
• Adjustment of risk estimation according to baseline risk of different nations or regions.
• Primary emphasis on lifestyle intervention; secondary emphasis on drug therapy.

The report is divided into primary and secondary prevention. For secondary prevention, priority is given to randomized controlled clinical trials (RCTs) because of a wealth of data. For primary prevention, recommendations are based on many years of accumulated research in epidemiology, genetics, basic science, and clinical trials.

To reduce long-term risk for ASCVD in primary prevention it is ideal to achieve atherogenic cholesterol in the optimal range. Several factors must be kept in mind when deciding how low to drive atherogenic cholesterol. Lifestyle therapies are first-line intervention; but depending on risk status, drug therapies may be necessary. Statins are first line therapy for achieving the optimal levels of atherogenic cholesterol in higher risk persons.
A general recommendation for adjusting intensity of therapy to absolute risk is shown in Table 1.

Table 1. IAS Recommendations for Cholesterol-Lowering Therapy at Different Risk Levels

Risk Level to Age 80 Yrs	Low (< 15%)	Moderate (15-24%)	Moderately High (25-40%)	High (> 40%)
Therapeutic Intensity		Moderate	Moderately High	High
Specific Therapy	Public health recommendationa	MLTb +CLDc optionald	MLTb +CLDc consideratione	MLTb +CLDc indicatedf

^a Persons at low risk for ASCVD should be treated according to national recommendation for the general public. These recommendations should accord with IAS recommendations for lifestyle therapies.
^b MLT = maximal lifestyle therapies.
^c CLD = cholesterol-lowering drug, usually a statin.
^d Cholesterol-lowering drug therapy usually reserved for patients with high levels of atherogenic cholesterol.
^e Statin therapy is widely recommended for this risk category, although it is not accepted in many countries because of cost considerations. If drugs are employed, the dose should be adequate to achieve optimal atherogenic-cholesterol levels.
^f Cholesterol-lowering drug therapy is usually indicated in this category. The dose should be adequate to achieve optimal atherogenic-cholesterol levels.

Source:
IAS Position Paper: Global Recommendations for the Management of Dyslipidemia.
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