Secondary prevention relies on early detection of disease process and application of interventions to prevent progression of disease. Primary prevention reduces the risk of MI and HF, decreases the need for coronary revascularization procedures, and extends and improves QoL. It should start with lifestyle modification, including smoking cessation, weight management, diet and physical activity.

The 2013 AHA/ACC guidelines on the management of elevated blood cholesterol no longer specify LDL-C and non-HDL-C targets for the primary and secondary prevention of ASCVD.

The AHA/ACC expert panel found evidence supporting the use of statins for the prevention of ASCVD in many higher-risk primary- and all secondary-prevention individuals without NYHA Class II-IV HF not receiving hemodialysis. In the RCTs reviewed, initiation of moderate-intensity therapy (lowering LDL-C by ~30% to <50%) or high-intensity statin therapy (lowering LDL-C by ~≥50%) was a critical factor in reducing ASCVD events. Moreover, statin therapy reduces ASCVD events across the spectrum of baseline LDL-C >70 mg/dL. For secondary prevention, individuals aged <75 years with clinical ASCVD should be started on high-intensity statin therapy unless contraindicated. In individuals with clinical ASCVD with contraindications to high-intensity statin therapy, but who would otherwise benefit from it, or in persons predisposed to statin-associated adverse effects, a second-line option is moderate-intensity statin therapy, if tolerated. The lipid goal is achieving LDL-C <100 mg/dL; if TGs are >200 mg/dL, non-HDL-C should be <130 mg/dL.

Assess fasting lipid profile in all patients and within 24 hours of hospitalization for those with an acute CV or coronary event. For hospitalized patients, before discharge, initiate lipid-lowering medication as recommended below:

1.LDL-C should be <100 mg/dL, and further reduction of LDL-C to <70 mg/dL is reasonable.2. If the baseline LDL-C is 100 mg/dL, initiate LDL-C-lowering drug therapy.3. If the patient is on treatment and LDL-C is 100 mg/dL, intensify LDL-C-lowering drug therapy (may require drug combination [standard dose of statin with ezetimibe, bile acid sequestrant or niacin]).4. If the baseline LDL-C is 70-100 mg/dL, treating to an LDL-C level <70 mg/dL is reasonable.5. If the TGs are 200-499 mg/dL, non-HDL-C should be <130 mg/dL, and further reduction of non-HDL-C to <100 mg/dL is reasonable.

Secondary prevention trials in older persons with CAD and hypercholesterolemia suggest that statins reduced all-cause mortality, CV mortality, coronary events, coronary revascularization, stroke and intermittent claudication.

Raal et al found that lipid-lowering therapy is associated with delayed CV events and prolonged survival in patients with homozygous familial hypercholesterolemia.