VA/DoD recommendations	ACC/AHA recommendations
Recommend using at least a moderate-dose statin	Initiate or continue moderate-intensity statin therapy in patients with clinical ASCVD in whom high-intensity statin therapy is contraindicated or who experience statin-associated adverse effects, with the aim of achieving a 30% to 49% reduction in LDL-C levels
Offer high-dose statins and add ezetimibe or PCSK9 inhibitors to moderate- or high-dose statins for higher-risk patients who are willing to intensify treatment; maximize statin dose and add ezetimibe before adding PCSK9 inhibitors	Initiate or continue high-intensity statin therapy in patients who are ≤ 75 years who have clinical ASCVD, with the aim of achieving a ≥ 50% reduction in LDL-C levels Reasonable to add ezetimibe therapy for patients with clinical ASCVD who are taking maximally tolerated statin therapy, who are judged to be at very high risk, and who have an LDL-C level of ≥ 70 mg per dL Reasonable to add PCSK9 inhibitor following a physician-patient discussion about the net benefit, safety, and cost in patients with clinical ASCVD who are judged to be very high risk and who are taking maximally tolerated LDL-C–lowering therapy with an LDL-C level of ≥ 70 mg per dL or a non–high-density lipoprotein cholesterol level of ≥ 100 mg per dL (2.59 mmol per L); at mid-2018 list prices, PCSK9 inhibitors have a low-cost value (> $150,000 per quality-adjusted life year)
Offer icosapent ethyl for patients taking statin therapy with persistently elevated fasting triglyceride levels > 150 mg per dL (1.69 mmol per L) to reduce cardiovascular morbidity and mortality	None (guideline published before REDUCE-IT trial of icosapent ethyl)
Suggest against the use of omega-3 fatty acids as a dietary supplement to reduce cardiovascular disease risk	None
For patients who cannot tolerate taking a statin, offer a washout period followed by a rechallenge with the same or different statin or lower dose; if that is ineffective, offer a trial of intermittent (nondaily) dosing	Reassess and rechallenge for patients with statin-associated adverse effects that are not severe to achieve a maximal LDL-C lowering by modified dosing regimen, an alternate statin, or in combination with nonstatin therapy
Suggest against the routine monitoring of lipid levels in patients taking statins	Assess adherence and percentage response to LDL-C–lowering medications and lifestyle changes with repeat lipid measurement 4 to 12 weeks after statin initiation or dose adjustment, repeated every 3 to 12 months as needed