Primary Prevention Adults 40 to 75 Years of Age With LDL-C Levels 70 to 189 mg/dL (1.7 to 4.8 mmol/L) Primary Prevention Recommendations for Adults 40 to 75 Years of Age With LDL Levels 70 to 189 mg/dL (1.7 to 4.8 mmol/L) Referenced studies that support recommendations are summarized in Online Data Supplement 16. COR LOE Recommendations I A In adults at intermediate-risk, statin therapy reduces risk of ASCVD, and in the context of a risk discussion, if a decision is made for statin therapy, a moderate-intensity statin should be recommended.S4.4.2-1 S4.4.2-8 I A In intermediate-risk patients, LDL-C levels should be reduced by 30% or more, and for optimal ASCVD risk reduction, especially in high-risk patients, levels should be reduced I B-NR For the primary prevention of clinical ASCVD* in adults 40 to 75 years of age without diabetes mellitus and with an LDL-C level of 70 to 189 mg/dL (1.7 to 4.8 mmol/L), the 10-year ASCVD risk of a first hard ASCVD event (fatal and nonfatal MI or stroke) should be estimated by using the race- and sex-specific PCE, and adults should be categorized as being at low risk (<5%), borderline risk (5% to <7.5%), intermediate- risk ( 7.5% to <20%), and high-risk I B-NR Clinicians and patients should engage in a risk discussion that considers risk factors, adherence to healthy lifestyle, the potential for ASCVD risk-reduction benefits, and the potential for adverse effects and drug drug interactions, as well as patient preferences, for an individualized treatment IIa B-R In intermediate-risk adults, risk-enhancing factors favor initiation or intensification of IIa B-NR In intermediate-risk or selected borderline-risk adults, if the decision about statin use remains uncertain, it is reasonable to use a CAC score in the decision to withhold, postpone or initiate statin IIa B-NR In intermediate-risk adults or selected borderline-risk adults in whom a CAC score is measured for the purpose of making a treatment decision, AND If the coronary calcium score is zero, it is reasonable to withhold statin therapy and reassess in 5 to 10 years, as long as higher risk conditions are absent (diabetes mellitus, family history of premature CHD, cigarette smoking); If CAC score is 1 to 99, it is reasonable to initiate statin therapy for patients 55 years of age; If CAC score is 100 or higher or in the 75th percentile or higher, it is reasonable to initiate statin therapy.S4.4.2-17,S4.4.2-23 CLINICAL STATEMENTS AND GUIDELINES IIb B-R In intermediate-risk adults who would benefit from more aggressive LDL-C lowering and in whom high-intensity statins are advisable but not acceptable or tolerated, it may be reasonable to add a nonstatin drug (ezetimibe or bile acid sequestrant) to a moderate-intensity IIb B-R In patients at borderline risk, in risk discussion, the presence of risk-enhancing factors may justify initiation of moderate- intensity statin therapy.S4.4.2-17,S4.4.2-24 *Definition of clinical ASCVD includes acute coronary syndrome (ACS), those with history of myocardial infarction (MI), stable or unstable angina or coronary or other arterial revascularization, stroke, transient ischemic attack (TIA), or peripheral artery disease (PAD) including aortic aneurysm, all of atherosclerotic origin. 