[52] A Spanish registry showed that of the 15% of HeFH patients with CV event history, only 1.3% were age 40 or under when they had their first event.[53] While statin therapy is reasonable for patients under age 40, there are no randomized primary prevention trials to demonstrate or quantify benefit. The evidence of the risks of non-continuous statin treatment (see Recommendation 23) suggests the decision to start therapy should be considered lifelong. Because this is a personal decision, shared decision making is even more essential in the absence of direct evidence. Despite the consistent evidence supporting the use of statins for primary CV event prevention, the NNT is large overall and increases for patients at lower risk. Informing patients of the risks of moderate-dose statins, where the DM risk is questionable and other risks have not been consistently demonstrated in trials, may be helpful in shared decision making. The low cost of generic statins and convenience of oral daily dosing further support their use. As these are Reviewed, New-replaced recommendations, the Work Group systematically reviewed evidence related to this recommendation [36-39,44,48-51] and considered the evidence put forth in the 2014 CPG.[40,42,45,47] The Work Group s confidence in the quality of the evidence for both recommendations was moderate. The body of evidence was primarily limited by study populations with wide variability in CV risk and varied inclusion criteria, leading to the retention of the 12% threshold and 6 12% risk range from the 2014 VA/DoD Dyslipidemia CPG. Given the consistent evidence of improvement in CV and all-cause mortality and reduction in MACE with limited harms, the Work Group determined that the benefits of moderate-dose statins outweighed the harms of treatment, but with an absolute improvement that varies based on baseline risk. 