If the LDL-C level on statin plus ezetimibe remains 100 mg/dL ( 2.6 mmol/L) and the patient has multiple factors that increase subsequent risk of ASCVD events, a PCSK9 inhibitor may be considered, although the long-term safety (>3 years) is uncer- tain and economic value is uncertain at mid-2018 list prices. 5. In patients 40 to 75 years of age with dia- betes mellitus and LDL-C 70 mg/dL ( 1.8 mmol/L), start moderate-intensity statin therapy without calculating 10-year ASCVD risk. In patients with diabetes mellitus at higher risk, especially those with multiple risk factors or those 50 to 75 years of age, it is reasonable to use a high-intensity statin to reduce the LDL-C level by 50%. 6. In adults 40 to 75 years of age evaluated for primary ASCVD prevention, have a clinician patient risk discussion before starting statin therapy. Risk discussion should include a review of major risk factors (eg, cigarette smoking, ele- vated blood pressure, LDL-C, hemoglobin A1C [if indicated], and calculated 10-year risk of ASCVD); the presence of risk-enhancing factors (see No. 8); the potential benefits of lifestyle and statin therapies; the potential for adverse effects and drug drug interactions; consideration of costs of statin therapy; and patient preferences and values in shared decision-making. 7. In adults 40 to 75 years of age without dia- betes mellitus and with LDL-C levels 70 mg/ dL ( 1.8 mmol/L), at a 10-year ASCVD risk of 7.5%, start a moderate-intensity statin if a discussion of treatment options favors statin therapy. Risk-enhancing factors favor statin ther- apy (see No. 8). If risk status is uncertain, consider using coronary artery calcium (CAC) to improve specificity (see No. 9). If statins are indicated, reduce LDL-C levels by 30%, and if 10-year risk is 20%, reduce LDL-C levels by 50%. 8. 