Red Flags
- 10-year PREVENT total-CVD risk ≥20% — high-risk; aggressive lipid lowering and BP control indicated regardless of symptoms[2]
- LDL-C ≥190 mg/dL — likely familial hypercholesterolaemia; high-intensity statin and family cascade screening[1]
- Diabetes with albuminuria or eGFR <60 — automatic high-risk regardless of calculated score; treat as secondary prevention equivalent[1]
- Strong family history of premature ASCVD (men <55, women <65) — risk-enhancing factor; lower threshold for statin[1]
First-line treatment
Interventions
- Lifestyle counselling[1]Mediterranean or DASH diet, ≥150 min/week moderate aerobic activity, weight reduction if BMI ≥25, sodium <2.3 g/day, smoking cessation, alcohol moderation
- Smoking cessation[1]Behavioural counselling plus pharmacotherapy (nicotine replacement, bupropion, or varenicline) for all who smoke
- Glycaemic management in diabetes[1]HbA1c target individualised (typically <7%); lifestyle plus metformin first-line; SGLT2 inhibitor or GLP-1 receptor agonist if established CVD or high CVD risk
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Atorvastatin[4] | HMG-CoA reductase inhibitor (statin) | 10–20 mg PO daily (moderate-intensity, intermediate-risk primary prevention); 40–80 mg (high-intensity, LDL-C ≥190 or PREVENT risk ≥20%) | 10 mg once daily for ages ≥10 with familial hypercholesterolaemia | First-line statin; 25–35% LDL-C reduction at moderate-intensity, 50%+ at high-intensity |
| Aspirin[1] | Antiplatelet (low dose) | 75–100 mg PO once daily | — | 2019 update reversed routine primary-prevention aspirin: use ONLY in select adults 40–70 at higher ASCVD risk and lower bleeding risk; not recommended ≥70 years or any age with elevated bleeding risk |
Atorvastatin[4]
HMG-CoA reductase inhibitor (statin)
- Adult
- 10–20 mg PO daily (moderate-intensity, intermediate-risk primary prevention); 40–80 mg (high-intensity, LDL-C ≥190 or PREVENT risk ≥20%)
- Paediatric
- 10 mg once daily for ages ≥10 with familial hypercholesterolaemia
First-line statin; 25–35% LDL-C reduction at moderate-intensity, 50%+ at high-intensity
Aspirin[1]
Antiplatelet (low dose)
- Adult
- 75–100 mg PO once daily
- Paediatric
- —
2019 update reversed routine primary-prevention aspirin: use ONLY in select adults 40–70 at higher ASCVD risk and lower bleeding risk; not recommended ≥70 years or any age with elevated bleeding risk
Safety-net
- Statins are taken lifelong — stopping causes cholesterol and cardiovascular risk to rebound rapidly[1]
- Daily aspirin is no longer routinely recommended for prevention — discuss bleeding risk with your clinician before starting or stopping[1]
- Reassess your cardiovascular risk every 4–6 years, or sooner if your weight, blood pressure, or family history changes[1]
Referral criteria
- LDL-C ≥190 mg/dL or strong family history of premature ASCVD or tendon xanthomasLipid clinic for familial hypercholesterolaemia evaluation and family cascade screening[4]
- PREVENT 10-year total-CVD risk ≥20% AND uncertain about statin-vs-no-statinCardiology or preventive cardiology clinic for shared decision making and CAC scoring[2]
- Resistant or secondary hypertension suspected during preventive workupHypertension clinic; refer to dedicated hypertension guideline[3]
Clinical summary
Risk-stratified prevention of atherosclerotic cardiovascular disease through lifestyle, lipid, BP, and glycaemic management in adults without known CVD.
References
- 1.2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease (risk framework updated 2024 by PREVENT equations; BP and lipid arms updated 2025 and 2026) (2019)
- 2.Development and Validation of the American Heart Association's PREVENT Equations. Circulation (2024)
- 3.2025 AHA/ACC Guideline for Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. Hypertension (2025)
- 4.2026 ACC/AHA Guideline on the Management of Dyslipidemia. Circulation (2026)