2 | Guideline Summary – 2014 

DISCLAIMER

This Clinical Practice Guideline is based on a systematic review of both clinical and epidemiological evidence. Developed 

by a panel of multidisciplinary experts (all practicing clinicians), it provides a clear explanation of the logical relationships 

between various care options and health outcomes while rating both the quality of the evidence and the strength of the 

recommendations.

These guidelines are not intended to represent TRICARE policy. Further, inclusion of recommendations for specific testing 

and/or therapeutic interventions within these guidelines does not guarantee coverage of civilian sector care. Additional 

information on current TRICARE benefits may be found at www.tricare.mil or by contacting your regional TRICARE Managed 

Care Support Contractor.

TABLE OF CONTENTS

BACKGROUND ................................................................................................................................................................. 3

ALGORITHM...................................................................................................................................................................... 6

RECOMMENDATIONS....................................................................................................................................................... 8

PHARMACOLOGICAL AGENTS ......................................................................................................................................10
2 | Guideline Summary – 2014 

DISCLAIMER

This Clinical Practice Guideline is based on a systematic review of both clinical and epidemiological evidence. Developed 

by a panel of multidisciplinary experts (all practicing clinicians), it provides a clear explanation of the logical relationships 

between various care options and health outcomes while rating both the quality of the evidence and the strength of the 

recommendations.

These guidelines are not intended to represent TRICARE policy. Further, inclusion of recommendations for specific testing 

and/or therapeutic interventions within these guidelines does not guarantee coverage of civilian sector care. Additional 

information on current TRICARE benefits may be found at www.tricare.mil or by contacting your regional TRICARE Managed 

Care Support Contractor.

TABLE OF CONTENTS

BACKGROUND ................................................................................................................................................................. 3

ALGORITHM...................................................................................................................................................................... 6

RECOMMENDATIONS....................................................................................................................................................... 8

PHARMACOLOGICAL AGENTS ......................................................................................................................................10
4 | Guideline Summary – 2014 

Algorithm Management of Dyslipidemia 

2

3

7

4

5

10

9

11

13

12

6

8

1

14

15

Yes

Yes

Yes

Yes

Yes

Yes

No

No

No

No

No

No

Does patient have:

 - CHF (EF < 35% & NYHA Class > 1), or

 - ESRD on Dialysis, or

- Life expectancy < 5 years?

[ B ]

Does patient have a 

history of ASCVD or ACS?

[ C ]

Recent ACS or 

recurrent ASCVD?

10 - year CVD risk 

6 - 12%

[ G ]

Shared decision 

making results in statin 

initiation or continuation?

[ E ]

10-year CVD risk > 12%, or

LDL-C ≥ 190, or

DM with HTN or smoking?

[ F ]

Advise moderate dose statin

Consider titrating to high dose

 as tolerated

[ E ]

Advise moderate dose 

statin

[ E ]

Exit algorithm

Discuss treatment benefit 

with patient [ B ]

Men >35 and women > 45 or any patient 

with ASCVD 

[ A ]

Positive lifestyle changes:

(Smoking,diet & exercise)

Optimize comorbid conditions

[ H ]

Calculate 10-year CVD risk:

- Measure lipids, blood pressure,

- Assess risk factors for CVD and 

medications

[ D ]

Repeat CVD risk evaluation:

If 6-12% risk every 2 years

If < 6% risk every 5 years

[ G ]

Routine monitoring and follow-up, 

including for adverse drugs effects

[ I]

Mediterranean diet plus

 positive lifestyle changes

[,H ]
4 | Guideline Summary – 2014 

Algorithm Management of Dyslipidemia 

2

3

7

4

5

10

9

11

13

12

6

8

1

14

15

Yes

Yes

Yes

Yes

Yes

Yes

No

No

No

No

No

No

Does patient have:

 - CHF (EF < 35% & NYHA Class > 1), or

 - ESRD on Dialysis, or

- Life expectancy < 5 years?

[ B ]

Does patient have a 

history of ASCVD or ACS?

[ C ]

Recent ACS or 

recurrent ASCVD?

10 - year CVD risk 

6 - 12%

[ G ]

Shared decision 

making results in statin 

initiation or continuation?

[ E ]

10-year CVD risk > 12%, or

LDL-C ≥ 190, or

DM with HTN or smoking?

[ F ]

Advise moderate dose statin

Consider titrating to high dose

 as tolerated

[ E ]

Advise moderate dose 

statin

[ E ]

Exit algorithm

Discuss treatment benefit 

with patient [ B ]

Men >35 and women > 45 or any patient 

with ASCVD 

[ A ]

Positive lifestyle changes:

(Smoking,diet & exercise)

Optimize comorbid conditions

[ H ]

Calculate 10-year CVD risk:

- Measure lipids, blood pressure,

- Assess risk factors for CVD and 

medications

[ D ]

Repeat CVD risk evaluation:

If 6-12% risk every 2 years

If < 6% risk every 5 years

[ G ]

Routine monitoring and follow-up, 

including for adverse drugs effects

[ I]

Mediterranean diet plus

 positive lifestyle changes

[,H ]
6 | Guideline Summary – 2014 

Recommendations

Assessment of Cardiovascular Risk

A

1. We recommend CVD risk screening for men > age 35 and women > age 45, including a lipid profile 

and a risk calculation. [Strong For]

2. We recommend against routine screening for dyslipidemia outside of the context of a cardiovascular 

risk assessment. [Strong Against]

B. 

• Patients with Severe Systolic Chronic Heart Failure (CHF), End Stage Renal Disease (ESRD) and on 

Dialysis, or a Limited Life Expectancy are excluded from this guideline

D. 

3. For risk calculation, we suggest a 10-year risk calculator. [Weak For]

C. 

4. We suggest that patients being considered for statin therapy be assessed for other CVD risk factors, 

including, but not be limited, to the following:

a. Age (males >35 and females >45)

b. Family history of premature coronary artery disease (CAD); definite myocardial infarction (MI) or 

sudden death before age 55 in father or other male first-degree relative, or before age 65 in mother 

or other female first-degree relative

c. Current tobacco use/cigarette smoking (or within the last one month)

d. Hypertension — (systolic blood pressure [SBP] >140 mmHg or diastolic blood pressure [DBP] >90 mmHg 

confirmed on more than one occasion, or current therapy with anti-hypertensive medications)

e. Diabetes mellitus — A diagnosis of DM is made if any of the following: a) Fasting plasma glucose 

(FPG) is ≥126 mg/dL on at least two occasions, or b) A single hemoglobin A1c (HbA1c) reading of ≥ 6.5%, 

confirmed with a FPG ≥126 mg/dL (these tests can be done on the same or different days); or c) HbA1c is 

≥ 7% on two occasions using a clinical laboratory methodology standardized to the net splanchnic glucose 

production (NSGP) (not at the point of care); or d) Symptoms of hyperglycemia and a casual (random) 

glucose ≥ 200 mg/dL on two occasions. However, casual (random) plasma glucose is not recommended as a 

routine screening test. (see VA/DoD DM CPG at: http://www.healthquality.va.gov/guidelines/CD/diabetes/DM2010_FUL-v4e.pdf)

f. Level of HDL-C (Less than 40 mg/dL confirmed on more than one occasion)

[Weak For]

Modified from the 2006 CPG without an updated systematic review of the evidence. *

5. We suggest against the routine use of high-sensitivity C-reactive protein (hsCRP) testing. [Weak Against]

6. We suggest against the routine use of coronary artery calcium (CAC) testing. [Weak Against]
6 | Guideline Summary – 2014 

Recommendations

Assessment of Cardiovascular Risk

A

1. We recommend CVD risk screening for men > age 35 and women > age 45, including a lipid profile 

and a risk calculation. [Strong For]

2. We recommend against routine screening for dyslipidemia outside of the context of a cardiovascular 

risk assessment. [Strong Against]

B. 

• Patients with Severe Systolic Chronic Heart Failure (CHF), End Stage Renal Disease (ESRD) and on 

Dialysis, or a Limited Life Expectancy are excluded from this guideline

D. 

3. For risk calculation, we suggest a 10-year risk calculator. [Weak For]

C. 

4. We suggest that patients being considered for statin therapy be assessed for other CVD risk factors, 

including, but not be limited, to the following:

a. Age (males >35 and females >45)

b. Family history of premature coronary artery disease (CAD); definite myocardial infarction (MI) or 

sudden death before age 55 in father or other male first-degree relative, or before age 65 in mother 

or other female first-degree relative

c. Current tobacco use/cigarette smoking (or within the last one month)

d. Hypertension — (systolic blood pressure [SBP] >140 mmHg or diastolic blood pressure [DBP] >90 mmHg 

confirmed on more than one occasion, or current therapy with anti-hypertensive medications)

e. Diabetes mellitus — A diagnosis of DM is made if any of the following: a) Fasting plasma glucose 

(FPG) is ≥126 mg/dL on at least two occasions, or b) A single hemoglobin A1c (HbA1c) reading of ≥ 6.5%, 

confirmed with a FPG ≥126 mg/dL (these tests can be done on the same or different days); or c) HbA1c is 

≥ 7% on two occasions using a clinical laboratory methodology standardized to the net splanchnic glucose 

production (NSGP) (not at the point of care); or d) Symptoms of hyperglycemia and a casual (random) 

glucose ≥ 200 mg/dL on two occasions. However, casual (random) plasma glucose is not recommended as a 

routine screening test. (see VA/DoD DM CPG at: http://www.healthquality.va.gov/guidelines/CD/diabetes/DM2010_FUL-v4e.pdf)

f. Level of HDL-C (Less than 40 mg/dL confirmed on more than one occasion)

[Weak For]

Modified from the 2006 CPG without an updated systematic review of the evidence. *

5. We suggest against the routine use of high-sensitivity C-reactive protein (hsCRP) testing. [Weak Against]

6. We suggest against the routine use of coronary artery calcium (CAC) testing. [Weak Against]
8 | Guideline Summary – 2014 

Non-pharmacological Approaches

H.

20. We recommend all adults adopt healthy lifestyles to reduce CVD risk, including: [Strong For]

a. Tobacco cessation for all smokers (See VA/DoD Tobacco Use CPG 2008 at:

http://www.healthquality.va.gov/guidelines/cd/mtu/index.asp )

b. Therapeutic Lifestyle Changes (TLC) diet to optimize nutrition 

(For overweight and/or obese patients, see VA/DoD CPG for Management Of Overweight And 

Obesity 2014 at:

http://www.healthquality.va.gov/guidelines/cd/obesity/index.asp )

c. Optimal physical activity (See 2008 Physical Activity Guidelines for Americans, at

http://www.health.gov/paguidelines/pdf/paguide.pdf )

Modified from the 2006 CPG without an updated systematic review of the evidence. *

21. We suggest offering high-risk patients (see text for definition) a dietitian-monitored Mediterranean 

diet supplemented with either extra-virgin olive oil (roughly 1 liter per week) or 30g of mixed nuts per 

day (15g of walnuts, 7.5g of hazelnuts, and 7.5g of almonds) for the reduction of CVD events. [Weak 

For]

22. We suggest that each patient’s diet be individualized based on a nutrition assessment (preferably by a 

RD), other CVD risk factors, other disease conditions, and patient’s lifestyle. [Weak For]

Modified from the 2006 CPG without an updated systematic review of the evidence. *

23. We recommend treating the common secondary causes of elevated TGs: dietary indiscretion (e.g., 

refined sugars), alcohol use, hypothyroidism, and hyperglycemia. [Strong For]

Modified from the 2006 CPG without an updated systematic review of the evidence. *

24. We suggest for patients with TGs greater than 500 mg/dL a strict diet therapy including avoidance of 

alcohol, restriction of dietary fat, and avoidance of refined sugars. We suggest for patients with TGs 

greater than 1000 mg/dL a very low fat diet to reduce chylomicronemia and risk of acute pancreatitis. 

[Weak For]

Follow-up

G.

25. We suggest CVD risk assessment every five years for patients with low CVD risk and not on statin 

therapy. [Weak For]

26. We suggest CVD risk assessment every two years for patients with intermediate CVD risk or with 

appearance of a new CVD risk factor (e.g., new diagnosis of type 2 DM or hypertension) and not on 

statin therapy. [Weak For]

* These “modified” recommendations from the previous CPG published in 2006 were considered still relevant to health care providers

 and were carried forward into this CPG. For additional information please refer to the section Reconciling 2006 CPG Recommendations 

in the full CPG
8 | Guideline Summary – 2014 

Non-pharmacological Approaches

H.

20. We recommend all adults adopt healthy lifestyles to reduce CVD risk, including: [Strong For]

a. Tobacco cessation for all smokers (See VA/DoD Tobacco Use CPG 2008 at:

http://www.healthquality.va.gov/guidelines/cd/mtu/index.asp )

b. Therapeutic Lifestyle Changes (TLC) diet to optimize nutrition 

(For overweight and/or obese patients, see VA/DoD CPG for Management Of Overweight And 

Obesity 2014 at:

http://www.healthquality.va.gov/guidelines/cd/obesity/index.asp )

c. Optimal physical activity (See 2008 Physical Activity Guidelines for Americans, at

http://www.health.gov/paguidelines/pdf/paguide.pdf )

Modified from the 2006 CPG without an updated systematic review of the evidence. *

21. We suggest offering high-risk patients (see text for definition) a dietitian-monitored Mediterranean 

diet supplemented with either extra-virgin olive oil (roughly 1 liter per week) or 30g of mixed nuts per 

day (15g of walnuts, 7.5g of hazelnuts, and 7.5g of almonds) for the reduction of CVD events. [Weak 

For]

22. We suggest that each patient’s diet be individualized based on a nutrition assessment (preferably by a 

RD), other CVD risk factors, other disease conditions, and patient’s lifestyle. [Weak For]

Modified from the 2006 CPG without an updated systematic review of the evidence. *

23. We recommend treating the common secondary causes of elevated TGs: dietary indiscretion (e.g., 

refined sugars), alcohol use, hypothyroidism, and hyperglycemia. [Strong For]

Modified from the 2006 CPG without an updated systematic review of the evidence. *

24. We suggest for patients with TGs greater than 500 mg/dL a strict diet therapy including avoidance of 

alcohol, restriction of dietary fat, and avoidance of refined sugars. We suggest for patients with TGs 

greater than 1000 mg/dL a very low fat diet to reduce chylomicronemia and risk of acute pancreatitis. 

[Weak For]

Follow-up

G.

25. We suggest CVD risk assessment every five years for patients with low CVD risk and not on statin 

therapy. [Weak For]

26. We suggest CVD risk assessment every two years for patients with intermediate CVD risk or with 

appearance of a new CVD risk factor (e.g., new diagnosis of type 2 DM or hypertension) and not on 

statin therapy. [Weak For]

* These “modified” recommendations from the previous CPG published in 2006 were considered still relevant to health care providers

 and were carried forward into this CPG. For additional information please refer to the section Reconciling 2006 CPG Recommendations 

in the full CPG
10 | Guideline Summary – 2014 

Table 7 . Summary of Statin and Non-statin Pharmacologic Agents

Drug Category Dose Adverse Drug Events Notes

Statins

Atorvastatin

10-80 mg once daily

(high dose = 40-80 mg) 

(moderate dose = 10-20 mg)

Statins are generally well tolerated. 

Myalgia, myopathy and rarely, 

rhabdomyolysis may occur. Risk 

of rhabdo is increased in the 

presence of interacting drugs, 

higher statin doses, renal or liver 

impairment, hypothyroidism, 

frailty, advanced age, etc.

Other adverse events include 

diabetes, LFT elevation and 

possible non-serious, reversible 

cognitive effects including 

memory loss and confusion.

However, an association between 

statins and an effect on cognition 

has not been confirmed.

First line therapy for primary or 

secondary prevention of ASCVD.

Monotherapy with statins represents 

the best evidence for cardiovascular 

Rosuvastatin risk reduction.

5-40 mg once daily

(high dose = 20-40 mg) 

(moderate dose = 5- 10mg)

Simvastatin 5-40 mg once daily

(moderate dose = 20-40 mg)

Lovastatin 20-80 mg once daily

(moderate dose = 40 mg)

Pravastatin 10-80 mg once daily

(moderate dose = 40-80 mg)

Fluvastatin

20-80 mg/day

(moderate dose = 40 mg 

twice daily or 80 mg XR/day)

Pitavastatin 1-4 mg once daily

(moderate dose = 2-4 mg)

Fibrates

Fenofibrate Nanocrystal 145 mg/day

Micronized 43-200 mg/day

Micronized taken with meals.

Dose varies depending upon 

micronized product used.

Skin rash, gastrointestinal 

(nausea, bloating, dyspepsia, 

cramping), headache myalgia, 

myopathy, increased serum 

transaminases, elevation in serum 

creatinine, cholelithiasis, etc.

Combination with a statin in the 

ACCORD trial showed no evidence of 

improved patient outcomes beyond 

statin based therapy (Subgroup 

analysis showed potential harm in 

women and a potential benefit in 

those with high TG and low HDL-C). [6]

Avoid in patients with CrCl < 30 ml/

min, active liver disease including 

primary biliary cirrhosis, and 

preexisting gallbladder disease.

Fenofibric Acid 35-105 mg once daily

Taken without regard to meals.

See Fenofibrate Avoid in patients with CrCl < 30 ml/

min, active liver disease including 

primary biliary cirrhosis, and 

preexisting gallbladder disease.

Gemfibrozil 600 mg twice daily

Take 30-60 min before meals.

See Fenofibrate VA-HIT (secondary prevention) 

gemfibrozil BID for 5 years vs. 

placebo in men with low HDL-C and 

moderately elevated LDL-C resulted in 

a significant reduction in nonfatal MI 

and death or cardiac origin. [7]

Avoid in patients with CrCl < 30 ml/

min, active liver disease including 

primary biliary cirrhosis, and 

preexisting gallbladder disease.

Note: Refer to product prescribing insert for more information regarding use restrictions, dose modification, dosing in special populations 

(e.g., renal or liver impairment, advanced age, pregnancy, etc.), drug-drug interactions and adverse events.
10 | Guideline Summary – 2014 

Table 7 . Summary of Statin and Non-statin Pharmacologic Agents

Drug Category Dose Adverse Drug Events Notes

Statins

Atorvastatin

10-80 mg once daily

(high dose = 40-80 mg) 

(moderate dose = 10-20 mg)

Statins are generally well tolerated. 

Myalgia, myopathy and rarely, 

rhabdomyolysis may occur. Risk 

of rhabdo is increased in the 

presence of interacting drugs, 

higher statin doses, renal or liver 

impairment, hypothyroidism, 

frailty, advanced age, etc.

Other adverse events include 

diabetes, LFT elevation and 

possible non-serious, reversible 

cognitive effects including 

memory loss and confusion.

However, an association between 

statins and an effect on cognition 

has not been confirmed.

First line therapy for primary or 

secondary prevention of ASCVD.

Monotherapy with statins represents 

the best evidence for cardiovascular 

Rosuvastatin risk reduction.

5-40 mg once daily

(high dose = 20-40 mg) 

(moderate dose = 5- 10mg)

Simvastatin 5-40 mg once daily

(moderate dose = 20-40 mg)

Lovastatin 20-80 mg once daily

(moderate dose = 40 mg)

Pravastatin 10-80 mg once daily

(moderate dose = 40-80 mg)

Fluvastatin

20-80 mg/day

(moderate dose = 40 mg 

twice daily or 80 mg XR/day)

Pitavastatin 1-4 mg once daily

(moderate dose = 2-4 mg)

Fibrates

Fenofibrate Nanocrystal 145 mg/day

Micronized 43-200 mg/day

Micronized taken with meals.

Dose varies depending upon 

micronized product used.

Skin rash, gastrointestinal 

(nausea, bloating, dyspepsia, 

cramping), headache myalgia, 

myopathy, increased serum 

transaminases, elevation in serum 

creatinine, cholelithiasis, etc.

Combination with a statin in the 

ACCORD trial showed no evidence of 

improved patient outcomes beyond 

statin based therapy (Subgroup 

analysis showed potential harm in 

women and a potential benefit in 

those with high TG and low HDL-C). [6]

Avoid in patients with CrCl < 30 ml/

min, active liver disease including 

primary biliary cirrhosis, and 

preexisting gallbladder disease.

Fenofibric Acid 35-105 mg once daily

Taken without regard to meals.

See Fenofibrate Avoid in patients with CrCl < 30 ml/

min, active liver disease including 

primary biliary cirrhosis, and 

preexisting gallbladder disease.

Gemfibrozil 600 mg twice daily

Take 30-60 min before meals.

See Fenofibrate VA-HIT (secondary prevention) 

gemfibrozil BID for 5 years vs. 

placebo in men with low HDL-C and 

moderately elevated LDL-C resulted in 

a significant reduction in nonfatal MI 

and death or cardiac origin. [7]

Avoid in patients with CrCl < 30 ml/

min, active liver disease including 

primary biliary cirrhosis, and 

preexisting gallbladder disease.

Note: Refer to product prescribing insert for more information regarding use restrictions, dose modification, dosing in special populations 

(e.g., renal or liver impairment, advanced age, pregnancy, etc.), drug-drug interactions and adverse events.
12 | Guideline Summary – 2014

REFERENCES

1. American Heart Association. What is cardiovascular disease (heart disease)? 2011; 

http://www.heart.org/HEARTORG/Caregiver/Resources/WhatisCardiovascularDisease/What-isCardiovascular-Disease_UCM_301852_Article.jsp. Accessed July 8, 2014.

2. Department of Veterans Affairs and Department of Defense. Clinical practice guideline 

for the management of dyslipidemia. 2006; http://www.healthquality.va.gov/guidelines/CD/

lipids/lip05_950_final2.pdf. Accessed December 1, 2014.

3. American Heart Association. What your cholesterol levels mean. 2014; http://www.heart.

org/HEARTORG/Conditions/Cholesterol/AboutCholesterol/What-Your-Cholesterol-LevelsMean_UCM_305562_Article.jsp. Accessed July 8, 2014.

4. Centers for Disease Control and Prevention (CDC). Vital signs: prevalence, treatment, 

and control of high levels of low-density lipoprotein cholesterol-United States, 1999-2002 

and 2005-200. MMWR Morb Mortal Wkly Rep. Feb 4 2011;60(4):109-114.

5. Lederle FA, Bloomfield HE. Drug treatment of asymptomatic hypertriglyceridemia to 

prevent pancreatitis: Where is the evidence? Ann Intern Med. Nov 6 2012;157(9):662-664.

6. Ginsberg HN, Elam MB, Lovato LC, et al. Effects of combination lipid therapy in type 2 

diabetes mellitus. N Engl J Med. Apr 29 2010;362(17):1563-1574.

7. Rubins HB, Robins SJ, Collins D, et al. Gemfibrozil for the secondary prevention of 

coronary heart disease in men with low levels of high-density lipoprotein cholesterol. 

Veterans Affairs high-density lipoprotein cholesterol intervention trial study group. N 

Engl J Med. Aug 5 1999;341(6):410-418.

8. Lavigne PM, Karas RH. The current state of niacin in cardiovascular disease prevention: A 

systematic review and meta-regression. J Am Coll Cardiol. Jan 29 2013;61(4):440-446.

9. Landray MJ, Haynes R, Hopewell JC, et al. Effects of extended-release niacin with 

laropiprant in high-risk patients. N Engl J Med. Jul 17 2014;371(3):203-212.

10. Rizos EC, Ntzani EE, Bika E, Kostapanos MS, Elisaf MS. Association between omega-3 

fatty acid supplementation and risk of major cardiovascular disease events: A systematic 

review and meta- analysis. JAMA. Sep 12 2012;308(10):1024-1033.
http://www.healthquality.va.gov

https://www.qmo.amedd.army.mil