Checklist for Clinician Patient Shared Decision-Making for Initiating Therapy Checklist Item Recommendation ASCVD risk assessment Assign to statin treatment group; use ASCVD Risk Estimator Plus.* In lower-risk primary-prevention adults 40-75 y of age with LDL-C 70 mg/dL ( 1.8 mmol/L). Not needed in secondary prevention, in those with LDL-C 190 mg/dL ( 4.9 mmol/L), or in those 40-75 y of age with diabetes mellitus. Assess other patient characteristics that influence risk. See Risk-Enhancing Factors (Section 4.4.1.3. and Table 6). Assess CAC (Section 4.4.1.4.) if risk decision is uncertain and additional information is needed to clarify ASCVD risk. Use decision tools to explain risk (eg, ASCVD Risk Estimator Plus,* Mayo Clinic Statin Choice Decision Aid ). Lifestyle modifications Review lifestyle habits (eg, diet, physical activity, weight or body mass index, and tobacco use). Endorse a healthy lifestyle and provide relevant advice, materials, or referrals (eg, CardioSmart , AHA Life s Simple 7 , NLA Patient Tear Sheets , PCNA Heart Healthy Toolbox , cardiac rehabilitation, dietitian, smoking cessation program). Potential net clinical benefit of pharmacotherapy Recommend statins as first-line therapy. Consider the combination of statin and nonstatin therapy in selected patients. Discuss potential risk reduction from lipid-lowering therapy. Discuss the potential for adverse effects or drug drug interactions. Cost considerations Discuss potential out-of-pocket cost of therapy to the patient (eg, insurance plan coverage, tier level, copayment). Shared decision- making Encourage the patient to verbalize what was heard (eg, patient s personal ASCVD risk, available options, and risks/benefits). Invite the patient to ask questions, express values and preferences, and state ability to adhere to lifestyle changes and medications. Refer patients to trustworthy materials to aid in their understanding of issues regarding risk decisions. Collaborate with the patient to determine therapy and follow-up plan. 