PMN 628005 does not start a statin and does not apply in familial hypercholesterolemia, pregnancy, or lactation. Do not put CCS modified-FRS cutoffs into the PEER Framingham decision aid, or PEER bands into the INESSS RCV or CCS FRS tools. CCS 2021 is five years old at the 2026-08-24 snapshot. Do not import US PREVENT engines or US lipid targets into a Québec or Canadian row.
Don't miss
PMN exclusions, TG, CK- INESSS Institut national d'excellence en santé et services sociaux
- PEER PEER (Patients, Experience, Evidence, Research), CFPC
- CCS Canadian Cardiovascular Society
| Decision | Guideline |
|---|---|
| PMN 628005 does not start a statin | PMN is titration for patients already on statin Adjusting statins and ezetimibe in adults already taking a statin, with or without ezetimibe.
INESSS, April 2025 opens in a new tabINESSS opens in a new tab |
| Framingham tools are not interchangeable | Three separate Framingham risk engines INESSS RCV calculator (Framingham-based, Québec-calibrated), PEER 2023 decision aid (original Framingham), and CCS 2021 modified FRS.
INESSS RCV calculator opens in a new tabPEER decision aid opens in a new tabPEER FAQ opens in a new tabCCS FRS calculator opens in a new tab |
| Triglycerides and pancreatitis | TG >4.5 mmol/L investigate secondary causes Secondary causes: alcohol, diabetes, hypothyroidism, medications.
INESSS opens in a new tabPEER 2023 CVD primary prevention in CFP opens in a new tabCCS 2021 lipids guideline hub opens in a new tab |
| CK and muscle symptoms | Stop statin if CK >10× ULN or severe symptoms Muscle pain or weakness on statin: check CK.
INESSS opens in a new tabCCS 2021 lipids guideline hub opens in a new tab |
Screening
PEER who/when- INESSS Institut national d'excellence en santé et services sociaux
- PEER PEER (Patients, Experience, Evidence, Research), CFPC
| Decision | Guideline |
|---|---|
| Who and when | Men ≥40, women ≥50Reassess CVD risk and lipids no more often than every 5 years, preferably every 10 years when on no treatment.
PEER 2023 in CFP opens in a new tabPEER 2023 DOI opens in a new tabPEER 2023 PMC opens in a new tab |
| Which test | Lipid panel fasting or non-fasting PMN 628005: total cholesterol, LDL-C, HDL-C, and triglycerides. Against fasting for global CVD risk
|
Diagnose
PEER start, statin-indicated- PEER PEER (Patients, Experience, Evidence, Research), CFPC
- CCS Canadian Cardiovascular Society
| Decision | Guideline |
|---|---|
| Statin-indicated conditions | ASCVD, AAA >3 cm, diabetes (ages), CKD except dialysis, LDL ≥5.0
|
| Primary prevention | |
| ≥20% | Discuss high-intensity statin PEER 2023 in CFP opens in a new tabPEER decision aid opens in a new tab Recommend statin |
| 10–19% | Discuss starting a statin, preferably moderate-intensity PEER 2023 in CFP opens in a new tabPEER decision aid opens in a new tab Consider statin if modifiers |
| <10% | Retest lipids in 5 to 10 years Suggest retesting lipids in 5 years at the earliest and preferably in 10 years, with risk estimation. PEER 2023 in CFP opens in a new tabPEER decision aid opens in a new tab |
Treat
PEER primaryPEER 2023 is the primary-prevention engine. Start bands live in Diagnose (high / moderate / low). Treat here is lifestyle and do-nots, then secondary intensification. Do not use Annex I optional LDL <2.0 mmol/L or ≥50% as primary prevention treat-to-target.
- INESSS Institut national d'excellence en santé et services sociaux
- PEER PEER (Patients, Experience, Evidence, Research), CFPC
- CCS Canadian Cardiovascular Society
| Decision | Guideline |
|---|---|
| Primary prevention | |
| Lifestyle and do-nots | Activity, Mediterranean diet, no non-statin, no lipid targets
PEER 2023 in CFP opens in a new tabPEER decision aid opens in a new tab |
| Secondary prevention | |
| First statin | Discuss high-intensity statin
PEER 2023 in CFP opens in a new tabPEER decision aid opens in a new tab High-intensity, or maximally tolerated |
| When to add on | Intensify if LDL-C ≥1.8 on max tolerated statin Intensify if LDL-C ≥1.8 mmol/L (or non-HDL ≥2.4 mmol/L / ApoB ≥0.7 g/L) on max tolerated statin. |
| What to add | Ezetimibe or PCSK9 Add ezetimibe or PCSK9 inhibitor when more risk reduction is wanted. PEER 2023 in CFP opens in a new tabPEER decision aid opens in a new tab |
| Icosapent | Only after ezetimibe or PCSK9 Fasting triglyceride criteria
|
| Québec titration | Ezetimibe add-on.
PCSK9 is not started in this protocol.
INESSS, April 2025 opens in a new tabINESSS opens in a new tab |
| Drug | Dose | Duration |
|---|---|---|
| Atorvastatin | 40–80 mg DIE | Ongoing |
| Rosuvastatin | 20–40 mg DIE | Ongoing |
Special groups
Diabetes, CKD, age, pregnancy- INESSS Institut national d'excellence en santé et services sociaux
- PEER PEER (Patients, Experience, Evidence, Research), CFPC
- CCS Canadian Cardiovascular Society
| Decision | Guideline |
|---|---|
| Diabetes | Statin for diabetes age ≥40, or ≥30 + 15 years, or microvascular disease Start statin regardless of lipid levels
|
| CKD | Statin for CKD, except dialysis eGFR <60 mL/min/1.73 m²: start statin.
|
| >75 | Continue if already on statin.
Weigh benefit vs polypharmacy if starting new. PEER 2023: age >75 with CVD, continue statin.
Primary prevention age >75, consider individual frailty, polypharmacy, goals of care before starting new statin.
|
| Pregnancy and lactation | Statins contraindicated
INESSS opens in a new tabCCS 2021 lipids guideline hub opens in a new tab |
| After pregnancy complications | Screen and consider statin after preeclampsia or gestational hypertension History of preeclampsia, gestational hypertension, or gestational diabetes: screen lipids postpartum and consider statin in primary prevention based on overall CVD risk (FRS and modifiers).
|
Reviewed 31 August 2026 against the official sources below.
Sources
Blue square: Québec · red round: Canada. The code names the body; each section's key gives its full name.