Melvyn Rubenfire, M.D., is the director of preventive cardiology at the University of Michigan Frankel Cardiovascular Center.


Rubenfire's perspective for clinicians at

NEW: Rubenfire's overall take (feel free to use): "The new guidelines for reducing the risk of atherosclerotic cardiovascular disease (ASCVD) though lipid management emphasizes the heart-healthy lifestyle for all, identifying and addressing each of the risk factors, and beginning in young adults 20-39yrs for whom a life-time risk can be discussed. The emphasis is on estimating risk of manifesting heart attacks, strokes, and vascular related deaths by reviewing each of the major risk factors (hypertension, smoking, diabetes, and LDL cholesterol) and using a risk calculator that provides an estimated 10yr risk of ASCVD events. There is the recognition that the highest risk patients benefit from very low LDL cholesterol levels (<70mg/dl) that often needs two cholesterol lowering drugs which may include the very potent and expensive non statin PCSK-9 antibody injections every 2 weeks.  The use of  moderate or high intensity (decrease LDL-C by >50%) statins depends on risk that is divided into intermediate, high, and very high based upon classic risk factors.

The new guideline encourages the use of  risk enhancing factors that include a recent ASCVD event, a family member with premature ASCVD, familial hypercholesterolemia, other diseases (chronic kidney disease, family history of premature ASCVD, inflammatory diseases such as psoriasis and chronic HIV), use of other biomarkers (LDL-C >160mg/dl, high triglyceride, elevated hsCRP, and high lipoprotein (a)) and in those for whom the decision is uncertain the use of the coronary calcium score. All clinicians should have the 10 Take-Home messages readily available as a guide and be able to use for discussions with patients."