Statins for primary prevention
Recommendations
USPSTF2022Grade B/C/I
Adults 40-75 with ≥1 CVD risk factor (dyslipidemia, diabetes, hypertension, or smoking) and 10-yr CVD risk ≥10%: start a statin (B). Risk 7.5-10%: selectively offer (C). Age 76 and older: evidence insufficient to start a statin for primary prevention (I).
Verify at USPSTF (opens in a new tab)ACC/AHA2026
New Dyslipidemia Guideline: use PREVENT (not Pooled Cohort Equations) to estimate 10-yr ASCVD risk. Intermediate risk 5-<10%: statin recommended after shared decision; borderline 3-<5%: reasonable. Statin for adults ≥40 with diabetes, CKD stage ≥3, or HIV.
Verify at ACC/AHA (opens in a new tab)ACC/AHA2026
LDL-C goals return: primary prevention below 100 mg/dL at borderline or intermediate risk and below 70 at high risk (10-yr PREVENT ≥10%); below 55 for very high-risk ASCVD. Measure Lp(a) at least once in adulthood; ≥125 nmol/L (≥50 mg/dL) is high. Coronary calcium scan for men ≥40 and women ≥45 at borderline or intermediate risk when it would change the statin decision; any calcium supports an LDL-C goal below 100.
Verify at ACC/AHA (opens in a new tab)VA/DoD2025Grade Strong for / Weak for
Primary prevention: at least a moderate-intensity statin with diabetes, 10-year risk ≥10%, or LDL-C ≥190 mg/dL (strong for); suggest a moderate-intensity statin at about 5% to <10% risk without diabetes (weak for), and for people with HIV even when risk is <5%. Suggests PREVENT for risk, CAC only at intermediate to high risk when it changes decisions, and measuring Lp(a) to identify enhanced risk. Suggests against adding fibrates or omega-3 supplements.
Verify at VA/DoD (opens in a new tab)Who this applies to
- USPSTF 2022: adults 40 to 75 with at least one risk factor (dyslipidemia, diabetes, hypertension or smoking) and a 10-year risk of 10 percent or more should start a statin (Grade B); 7.5 to under 10 percent, selectively offer (Grade C); 76 and older, insufficient evidence (I).
- ACC and AHA 2026: estimate risk with the PREVENT equations. A 10-year risk of 5 to under 10 percent supports a statin after shared decision-making; 3 to under 5 percent makes one reasonable. Adults 40 and older with diabetes, CKD stage 3 or worse, or HIV get a statin regardless of the score.
- LDL cholesterol of 190 mg/dL or more at any age: a high-intensity statin with no risk score needed, and an evaluation for familial hypercholesterolemia.
How it is done in practice
- A non-fasting lipid panel is fine for screening; repeat fasting if triglycerides exceed 400.
- PREVENT uses age, sex, cholesterol, blood pressure, diabetes, smoking, eGFR and use of blood pressure or statin drugs, with optional A1c, urine albumin and zip code. It produces lower estimates than the older Pooled Cohort Equations, so fewer people cross a given threshold at the same age.
- Moderate intensity (atorvastatin 10 to 20, rosuvastatin 5 to 10, simvastatin 20 to 40, pravastatin 40 to 80) lowers LDL by 30 to 49 percent; high intensity (atorvastatin 40 to 80, rosuvastatin 20 to 40) by 50 percent or more. Recheck 4 to 12 weeks after starting, then every 3 to 12 months.
- Undecided in the middle band: a coronary artery calcium score. A score of 0, in someone who does not smoke and has no diabetes or family history of early disease, supports deferring; any calcium supports a statin with an LDL goal under 100 (ACC and AHA 2026).
- Risk enhancers that tip a borderline decision: premature ASCVD in the family, LDL 160 or more, metabolic syndrome, CKD, preeclampsia or early menopause, chronic inflammatory disease, South Asian ancestry, persistent triglycerides of 175 or more, Lp(a) of 50 mg/dL or more, hs-CRP of 2 or more, or an ankle-brachial index under 0.9. Measure Lp(a) once in a lifetime.
What changed recently
The 2026 ACC and AHA guideline replaced the Pooled Cohort Equations with PREVENT, set new statin thresholds (recommended at 5 percent after discussion, reasonable at 3 percent), and brought back LDL goals: under 100 mg/dL at borderline or intermediate risk, under 70 at high risk and under 55 in very high-risk ASCVD. The USPSTF still keys on 10 percent. The two will disagree for many patients in the 5 to 10 percent band; that is the shared decision zone, and it is fine to say so out loud.
Points that matter in clinic
- Most statin muscle symptoms are not caused by the statin (the SAMSON trial found the same symptoms on placebo). Lower the dose, switch agents or use alternate-day rosuvastatin before giving up. Check CK only for severe symptoms.
- Diabetes at 40 to 75 earns at least a moderate-intensity statin; with one or more other risk factors, high intensity aiming for LDL under 70 (ADA 2026).
- At 76 and older, continuing a statin is reasonable; starting one is an individual decision based on health and preference.