lipidcalc.ca
2021 Canadian Cardiovascular Society Lipid Guidelines. Quickly determine need for lipid-lowering therapy. Note: This tool is not endorsed by the CCS. For all patient management decisions, please refer to the guidelines (PDF).
Choose lipid measurement:
LDL-C
ApoB
Non-HDL-C
?
Show Doses
Show Therapy
Use Non-HDL-C or ApoB if triglycerides are >1.5 mmol/L as LDL-C may underestimate atherogenic lipids.
#1: Are statin-indicated conditions present? Choose all that apply.
Atherosclerotic Cardiovascular Disease
?
Start initial therapy:
If despite statin LDL-C is:
If despite statin ApoB is:
If despite statin Non-HDL-C is:
Consider adding:
High-intensity statin
1.8–2.2 mmol/L
0.70–0.80 g/L
2.4–2.9 mmol/L
Ez ± PCSK9
>2.2 mmol/L
>0.80 g/L
>2.9 mmol/L
PCSK9 ± Ez
  • Ischemic heart disease: Myocardial infarction (MI), acute coronary syndrome (ACS), stable angina, documented coronary artery disease using angiography or
  • Cerebrovascular disease: Stroke, TIA, documented carotid disease or
  • Peripheral arterial disease, claudication, and/or ABI <0.9 or
  • Abdominal aortic aneurysm: abdominal aorta > 3.0 cm or previous aneurysm surgery
Most patients with diabetes
?
Start initial therapy:
If despite statin LDL-C is:
If despite statin ApoB is:
If despite statin Non-HDL-C is:
Consider adding:
Statin
≥2.0 mmol/L
≥0.80 g/L
≥2.6 mmol/L
Ez
  • Age ≥40 or
  • Age ≥30 with diabetes for ≥15 years or
  • Microvascular disease
Chronic Kidney Disease
?
Start initial therapy:
If despite statin LDL-C is:
If despite statin ApoB is:
If despite statin Non-HDL-C is:
Consider adding:
Statin
≥2.0 mmol/L
≥0.80 g/L
≥2.6 mmol/L
Ez
  • Age ≥50 and:
    • eGFR < 60 mL/min/1.73 m² or
    • ACR > 3 mg/mmol
Calculate eGFR
(CKD-EPI 2021)
Age:
Creatinine (mcmol/L):
Sex:
eGFR:
LDL-C ≥5.0 mmol/L ApoB ≥1.45 g/L Non-HDL-C ≥5.8 mmol/L
?
Start initial therapy:
If despite statin LDL-C is:
If despite statin ApoB is:
If despite statin Non-HDL-C is:
Consider adding:
Statin
≥2.5 mmol/L or reduced <50%
≥0.85 g/L or reduced <50%
≥3.2 g/L or reduced <50%
Ez or PCSK9
  • Familial hypercholesterolemia or genetic dyslipidemia
Next
#2: In selected patients with ASCVD or diabetes, are triglycerides elevated?
Triglycerides ≥1.5 mmol/L in selected patients
?
Start initial therapy: If despite statin triglycerides are: Consider adding:
Statin 1.5–5.6 mmol/L Icosapent ethyl
  • Triglycerides 1.5–5.6 mmol/L despite statin therapy and:
    • ASCVD or
    • Diabetes requiring medication and age ≥50 in addition to at least one additional risk factor:
      • Man age ≥55 or
      • Woman age ≥65y or
      • Smoked within last 3 months or
      • Hypertension or
      • HDL-C ≤1.04 mmol/L for men or ≤1.3 mmol/L for women or
      • hsCRP >3.0 mg/L, eGFR 30–60 mL/min or
      • Microvascular disease or
      • ABI <0.9 without claudication
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Next
#3: If there are no statin-indicated conditions, what is the modified Framingham Risk Score?
Calculate modified FRS
Age:
TC (mmol/L):
HDL-C (mmol/L):
Sex:
SBP (mmHg):
BP treated
Smoker
Family history
FRS:
≥20%
Start initial therapy:
If despite statin LDL-C is:
If despite statin ApoB is:
If despite statin Non-HDL-C is:
Consider adding:
Statin
≥2.0 mmol/L
≥0.80 g/L
≥2.6 mmol/L
Ez
10–19.9%
?
LDL-C ≥3.5 mmol/LApoB ≥1.05 g/LNon-HDL-C ≥4.2 mmol/L or risk modifier
Start initial therapy:
If despite statin LDL-C is:
If despite statin ApoB is:
If despite statin Non-HDL-C is:
Consider adding:
Statin
≥2.0 mmol/L
≥0.80 g/L
≥2.6 mmol/L
Ez
LDL-C <3.5 mmol/LApoB <1.05 g/LNon-HDL-C <4.2 mmol/L and no risk modifiers
No pharmacologic therapy indicated
Risk modifiers:
  • Men ≥50 or
  • Women ≥50y with at least one of:
    • Low HDL-C or
    • IFG or
    • High waist circumference or
    • Smoker or
    • HTN or
  • hsCRP ≥2.0 mg/mL or
  • Coronary artery calcium score >0 AU or
  • Family history of premature CAD or
  • Lp(a) ≥50 mg/dL (100 nmol/L)
5–9.9%
?
LDL-C ≥3.5 mmol/LApoB ≥1.05 g/LNon-HDL-C ≥4.2 mmol/L
Start initial therapy:
If despite statin LDL-C is:
If despite statin ApoB is:
If despite statin Non-HDL-C is:
Consider adding:
Statin
≥2.0 mmol/L
≥0.80 g/L
≥2.6 mmol/L
Ez
LDL-C <3.5 mmol/LApoB <1.05 g/LNon-HDL-C <4.2 mmol/L
No pharmacologic therapy indicated
Consider statin if LDL-C ≥ 3.5 mmol/LApoB ≥1.05 g/LNon-HDL-C ≥4.2 mmol/L especially in the presence of a risk modifier:
  • Coronary artery calcium score > 0 AU
  • family history of premature CAD
  • Lp(a) ≥ 50 mg/dL (100 nmol/L)
<5%
No pharmacologic therapy indicated
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Start Over
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Atherosclerotic Cardiovascular Disease with Elevated Triglycerides
  • Initial therapy: High-intensity statin
  • If LDL-C is 1.8–2.2 mmol/LApoB is 0.70–0.80 g/LNon-HDL-C is 2.4–2.9 mmol/L despite maximally tolerated statin, consider adding ezetimibe.
  • If LDL-C is >2.2 mmol/LApoB is >0.80 g/LNon-HDL-C is >2.9 mmol/L despite maximally tolerated statin, consider adding PCSK9 inhibitor as ezetimibe alone is unlikely to adequately lower lipids.
  • If triglycerides are 1.5–5.6 mmol/L despite maximally tolerated statin, consider adding icosapent ethyl.
Atherosclerotic Cardiovascular Disease
Initial therapy: High-intensity statin
  • If LDL-C is 1.8–2.2 mmol/LApoB is 0.70–0.80 g/LNon-HDL-C is 2.4–2.9 mmol/L despite maximally tolerated statin, consider adding ezetimibe.
  • If LDL-C is >2.2 mmol/LApoB is >0.80 g/LNon-HDL-C is >2.9 mmol/L despite maximally tolerated statin, consider adding PCSK9 inhibitor as ezetimibe alone is unlikely to adequately lower lipids.
Diabetes with Elevated Triglycerides
  • Initial therapy: Statin
  • If LDL-C is ≥2.0 mmol/LApoB is ≥0.80 g/LNon-HDL-C is ≥2.6 mmol/L despite maximally tolerated statin, consider adding ezetimibe. Bile acid sequestrants are an alternative.
  • If triglycerides are 1.5–5.6 mmol/L despite maximally tolerated statin, consider adding icosapent ethyl.
Diabetes
  • Initial therapy: Statin
  • If LDL-C is ≥2.0 mmol/LApoB is ≥0.80 g/LNon-HDL-C is ≥2.6 mmol/L despite maximally tolerated statin, consider adding ezetimibe. Bile acid sequestrants are an alternative.
Chronic Kidney Disease
  • Initial therapy: Statin
  • If LDL-C is ≥2.0 mmol/LApoB is ≥0.80 g/LNon-HDL-C is ≥2.6 mmol/L despite maximally tolerated statin, consider adding ezetimibe. Bile acid sequestrants are an alternative.
Familial Hypercholesterolemia or Genetic Dyslipidemia
  • Initial therapy: Statin
  • If LDL-C is ≥2.5 mmol/L or is reduced by <50%ApoB is ≥0.85 g/LNon-HDL-C is ≥3.2 mmol/L despite maximally tolerated statin, consider adding ezetimibe or PCSK9 inhibitor.
Primary prevention, high FRS
  • Initial therapy: Statin
  • If LDL-C is ≥2.0 mmol/LApoB is ≥0.80 g/LNon-HDL-C is ≥2.6 mmol/L despite maximally tolerated statin, consider adding ezetimibe. Bile acid sequestrants are an alternative.
Primary prevention, intermediate FRS with LDL-C ≥3.5 mmol/LApoB ≥1.05 g/LNon-HDL-C ≥4.2 mmol/L or risk modifier
  • Initial therapy: Statin
  • If LDL-C is ≥2.0 mmol/LApoB is ≥0.80 g/LNon-HDL-C is ≥2.6 mmol/L despite maximally tolerated statin, consider adding ezetimibe. Bile acid sequestrants are an alternative.
Primary prevention, low FRS
  • No statin indicated
  • Health behaviour modifications are recommended for all, including smoking cessation, a healthy dietary pattern and 150 min/week of moderate-vigorous intensity aerobic physical activity. Repeat cardiovascular risk assessment every 5 years for men and women aged 40–75.
Primary prevention, low risk with FRS 5–9.9% and LDL-C ≥3.5 mmol/LApoB ≥1.05 g/LNon-HDL-C ≥4.2 mmol/L
  • Initial therapy: Statin recommended as proportional benefit may be similar to other treated groups
  • If LDL-C is ≥2.0 mmol/LApoB is ≥0.80 g/LNon-HDL-C is ≥2.6 mmol/L despite maximally tolerated statin, consider adding ezetimibe. Bile acid sequestrants are an alternative.
Primary prevention, low risk
  • No statin indicated
  • Health behaviour modifications are recommended for all, including smoking cessation, a healthy dietary pattern and 150 min/week of moderate-vigorous intensity aerobic physical activity. Repeat cardiovascular risk assessment every 5 years for men and women aged 40–75.
Primary prevention, low risk
  • No statin indicated
  • Health behaviour modifications are recommended for all, including smoking cessation, a healthy dietary pattern and 150 min/week of moderate-vigorous intensity aerobic physical activity. Repeat cardiovascular risk assessment every 5 years for men and women aged 40–75.
Note: Multiple indications for lipid-lowering therapy are present. This box provides information on the indication with the lowest lipid goals.
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Statin (mg)
daily unless
specified
Intensity
High Moderate Low
Atorvastatin 40–80 10–20
Rosuvastatin 20–40 5–10
Simvastatin 20–40 10
Pravastatin 40–80 10–20
Lovastatin 40–80 20
Fluvastatin XL 80
Fluvastatin 40 BID 20–40
Ezetimibe 10 mg daily
PCSK9 inhibitors
Alirocumab 75-150 mg q2 weeks or 300 mg q4 weeks
Evolocumab 140 mg q2 weeks or 420 mg q4 weeks
Inclisiran 284 mg at 0, 3 and 6 months then q6 months
Icosapent ethyl 2 g BID with meals
Bile acid sequestrants
Cholestyramine 2–24 g daily
Colesevelam 2.5–3.75 g in 1–2 divided doses daily
Colestipol 5–30 g daily