Linking To And Excerpting From The 2026 Guideline On The Management Of Dyslipidemia

Posted on October 30, 2026 by Tom Wade MD

Today, I review, link to, and excerpt from the 2026 ACC/AHA/AACVPR/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Dyslipidemia: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines [PubMed Abstract] [Full-Text HTML] [Full-Text PDF]. J Am Coll Cardiol. 2026 May 19;87(19):2624-2757. doi: 10.1016/j.jacc.2025.11.016. Epub 2026 Mar 13.

All that follows is from the above resource.

Abstract

AIM

The “2026 ACC/AHA/AACVPR/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Dyslipidemia” retires and replaces the “2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol.”

METHODS

A comprehensive literature search was conducted from October 2024 to December 2024 to identify clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

The focus of this clinical practice guideline is to address the evaluation, management, and monitoring of individuals with dyslipidemias, including high blood cholesterol, hypertriglyceridemia, and elevated lipoprotein(a).

Table of Contents

4.

What Is New

Table 1 highlights new and/or substantially revised practice-changing recommendations since the last iteration of the guideline and is not a comprehensive list of all updates. Some of these recommendations have corresponding footnotes not captured in this table.
Table 1. What Is New
New or Revised Section Title 2018 Recommendation 2026 Recommendation
Revised 3.2. Measurement of TC, LDL-C, HDL-C, TG, and Non–HDL-C COR 2a: For adults with an LDL-C level <70 mg/dL (<1.8 mmol/L), measurement of direct LDL-C or modified LDL-C estimate is reasonable to improve accuracy over the Friedewald formula. COR 1: In adults and children who have undergone a standard lipid profile, use of either the Martin/Hopkins equation or the Sampson/NIH equation is preferred over calculation by the Friedewald equation to estimate LDL-C.
New 3.3. Measurement of ApoB N/A COR 2a: In adults on LLT, particularly those with ASCVD, CKM syndrome, type 2 diabetes, and/or elevated TG, measurement of apoB is reasonable to guide decisions regarding further therapeutic intensification once LDL-C and/or non–HDL-C goals are achieved.
New 3.4. Measurement of Lp(a) N/A COR 1: In all adults, measurement of Lp(a) concentration is recommended at least once for ASCVD risk assessment.
New 4.1.5. Dietary Supplements N/A COR 3: In individuals with dyslipidemia, the use of dietary supplements is not recommended to lower LDL-C or TG based on limited and inconsistent data and/or limited benefits in lipid-lowering and reduction in ASCVD risk.
New 4.1.6. When to Refer to a Registered Dietitian Nutritionist N/A COR 1: In individuals with fasting TG ≥1000 mg/dL (11.3 mmol/L) referral to an RDN is recommended to create an individualized treatment plan aimed at reducing TG and the risk of pancreatitis.
New 4.1.6. When to Refer to a Registered Dietitian Nutritionist N/A COR 2a: In individuals with fasting TG ≥150 to 999 mg/dL (≥1.7-11.3 mmol/L) and features of the CKM syndrome, referral to an RDN is recommended to provide counseling on evidence-based dietary patterns that can be beneficial to improve lipoprotein levels and reduce the risk of pancreatitis.
New 4.2.3.2. PREVENT-ASCVD Equations N/A COR 1: In adults aged 30 to 79 y without ASCVD or subclinical atherosclerosis and with an LDL-C level between 70 and 189 mg/dL (1.8-4.9 mmol/L), the PREVENT-ASCVD equations should be used to estimate 10-y ASCVD risk, with categorization as having low (<3%), borderline (3% to <5%), intermediate (5% to <10%), or high (≥10%) risk.
Revised 4.2.3.3. Risk Enhancers COR 2b: In patients at borderline risk, in risk discussion, the presence of risk-enhancing factors may justify initiation of moderate-intensity statin therapy. COR 2a: In adults without ASCVD with a borderline 10-y ASCVD risk estimate (3% to <5%) by the PREVENT-ASCVD equations, consideration of risk enhancers is reasonable to personalize risk assessment and the potential benefit of initiating LLT as an adjunct to lifestyle management to reduce ASCVD risk.
New 4.2.3.3. Risk Enhancers N/A COR 2a: In adults without ASCVD with a borderline 10-y ASCVD risk estimate (3% to <5%) by the PREVENT-ASCVD equations, if hsCRP is measured and is ≥2 mg/L on 2 successive occasions with no identifiable underlying cause of hsCRP elevation, high-intensity statin therapy can be useful to reduce the risk of ASCVD events.
New 4.2.3.4. Reproductive Risk Markers N/A COR 2a: In adults without ASCVD, consideration of reproductive risk markers, such as early menopause (<45 y old) and history of adverse pregnancy outcomes (gestational hypertension, preeclampsia, gestational diabetes, preterm delivery) is reasonable to personalize ASCVD risk assessment when considering the potential benefit of initiating LLT as an adjunct to lifestyle management for primary ASCVD prevention.
Revised 4.2.3.6. Selective Imaging of Subclinical Atherosclerosis COR 2a: In intermediate-risk or selected borderline-risk adults, if the decision about statin use remains uncertain, it is reasonable to use a CAC score in the decision to withhold, postpone, or initiate statin therapy. COR 1: In adults at intermediate risk and select adults at borderline risk with no prior ASCVD, if the decision regarding LLT remains uncertain, a CAC score should be used for further risk stratification and to guide the decision to withhold, postpone, or initiate therapy.
New 4.2.3.6. Selective Imaging of Subclinical Atherosclerosis N/A COR 2a: In adults at intermediate risk or select adults at borderline risk who undergo CAC testing, if the CAC score is 0 AU and there is preference to avoid LLT and focus on lifestyle management and no higher risk conditions (FH or severe hypercholesterolemia ≥190 mg/dL, diabetes and age >40 y, current cigarette smoking, strong family history of premature ASCVD) are present, it is reasonable to defer therapy and reassess with repeat CAC testing in 3 to 7 y to personalize management.
New 4.2.3.6. Selective Imaging of Subclinical Atherosclerosis N/A COR 1: In adults at intermediate risk and select adults at borderline risk, if the CAC score is >0 AU, it is recommended to initiate LLT, particularly if the CAC score is ≥100 AU or ≥75th standardized percentile to reduce ASCVD risk.
New 4.2.3.6. Selective Imaging of Subclinical Atherosclerosis N/A COR 2a: In adults at intermediate or high risk with no prior ASCVD, if there is uncertainty about the intensity of LLT, a CAC score can be useful to refine treatment goals and decide whether to intensify lipid-lowering therapies.
New 4.2.3.6. Selective Imaging of Subclinical Atherosclerosis N/A COR 1: In adults with no prior ASCVD, if incidental CAC is identified on noncardiac CT scans (eg, by visual estimation or a validated artificial intelligence–based algorithm), the presence of coronary atherosclerosis should be considered during decision-making about initiation or intensification of LLT to reduce ASCVD risk.
New 4.2.3.7. Management in Primary Prevention in Adults 30 to 79 Years of Age With LDL-C Levels 70 to 189 mg/dL (1.8-4.9 mmol/L) N/A COR 1: In adults at low (<3%) 10-y estimated risk for ASCVD who have an LDL-C <160 mg/dL (4.1 mmol/L) and a 30-y risk estimate of <10% (for those aged 30-59 y), counseling on health behaviors is recommended to reduce LDL-C and risk for ASCVD.
New 4.2.3.7. Management in Primary Prevention in Adults 30 to 79 Years of Age With LDL-C Levels 70 to 189 mg/dL (1.8-4.9 mmol/L) N/A COR 2a: In adults at low (<3%) 10-y estimated risk for ASCVD but with an LDL-C of 160 to 189 mg/dL (4.1-4.9 mmol/L) or a 30-y ASCVD risk ≥10% (for those aged 30-59 y), a moderate-intensity statin is reasonable to reduce cumulative exposure to atherogenic lipoproteins.
New 4.2.3.7. Management in Primary Prevention in Adults 30 to 79 Years of Age With LDL-C Levels 70 to 189 mg/dL (1.8-4.9 mmol/L) N/A COR 2a: In adults at borderline (3% to <5%) 10-y estimated risk for ASCVD risk in whom a decision is made to initiate statin therapy for primary prevention, a moderate-intensity statin is reasonable to achieve ≥30% to 49% LDL-C reduction and to reduce ASCVD risk.
New 4.2.3.7. Management in Primary Prevention in Adults 30 to 79 Years of Age With LDL-C Levels 70 to 189 mg/dL (1.8-4.9 mmol/L) N/A COR 1: In adults at intermediate (5% to <10%) 10-y estimated risk for ASCVD, at least a moderate-intensity statin is recommended to achieve ≥30% to 49% LDL-C reduction and to reduce ASCVD risk; for those in the higher end of this risk range, a high-intensity statin is beneficial to further reduce LDL-C by ≥50% and reduce ASCVD risk.
New 4.2.3.7. Management in Primary Prevention in Adults 30 to 79 Years of Age With LDL-C Levels 70 to 189 mg/dL (1.8-4.9 mmol/L) N/A COR 2a: In adults at borderline (3% to <5%) or intermediate (5% to <10%) 10-y estimated risk for ASCVD in whom statin therapy is initiated, it is reasonable to treat to a goal of LDL-C <100 mg/dL (2.6 mmol/L) and non–HDL-C <130 mg/dL (3.4 mmol/L) to reduce ASCVD risk.
New 4.2.3.7. Management in Primary Prevention in Adults 30 to 79 Years of Age With LDL-C Levels 70 to 189 mg/dL (1.8-4.9 mmol/L) N/A COR 1: In adults at high (≥10%) 10-y risk for ASCVD in whom LLT is initiated for primary prevention, high-intensity statin therapy is recommended to achieve an LDL-C reduction of ≥50% to reduce the risk of ASCVD.
New 4.2.3.7. Management in Primary Prevention in Adults 30 to 79 Years of Age With LDL-C Levels 70 to 189 mg/dL (1.8-4.9 mmol/L) N/A COR 2a: In adults at high (≥10%) 10-y risk for ASCVD in whom a decision to initiate statin therapy is made, it is reasonable to treat to a goal of LDL-C <70 mg/dL (1.8 mmol/L) and non–HDL-C <100 mg/dL (2.6 mmol/L) to reduce ASCVD risk.
New 4.2.3.7. Management in Primary Prevention in Adults 30 to 79 Years of Age With LDL-C Levels 70 to 189 mg/dL (1.8-4.9 mmol/L) N/A COR 2a: In adults at high (≥10%) 10-y estimated risk for ASCVD on maximally tolerated statin, it is reasonable to add ezetimibe if a goal LDL-C <70 mg/dL (1.8 mmol/L) and non–HDL-C <100 mg/dL (2.6 mmol/L) is not achieved.
New 4.2.4.1. Role of Risk Assessment in HeFH N/A COR 3: In individuals with HeFH, standard risk assessment tools developed for the general population should not be used to calculate 10- or 30-y ASCVD risk.
New 4.3.3.2. Genetic Testing for FH N/A COR 2a: In adults with severe hypercholesterolemia with an LDL-C ≥190 mg/dL (4.9 mmol/L) without an identified secondary cause, panel-based genetic testing for pathogenic/likely pathogenic rare variants for FH can be useful to identify those with FH who are at higher risk of ASCVD events.
Revised 4.2.4.3. Severe Hypercholesterolemia With LDL-C ≥190 mg/dL (4.9 mmol/L) COR 2a: In patients 20 to 75 years of age with an LDL-C level of 190 mg/dL or higher (4.9 mmol/L) who achieve less than a 50% reduction in LDL-C while receiving maximally tolerated statin therapy and/or have an LDL-C level of 100 mg/dL or higher (2.6 mmol/L), ezetimibe therapy is reasonable. COR 1: In adults with severe hypercholesterolemia with an LDL-C ≥190 mg/dL (4.9 mmol/L) and without clinical ASCVD, additional ASCVD risk factors, HeFH, or subclinical atherosclerosis who are on maximally tolerated statin therapy, the addition of ezetimibe, a PCSK9 mAb and/or bempedoic acid is recommended to achieve a goal of LDL-C <100 mg/dL (2.6 mmol/L) and a non–HDL-C goal of <130 mg/dL (3.4 mmol/L) and to reduce ASCVD risk.
Revised 4.2.4.3. Severe Hypercholesterolemia With LDL-C ≥190 mg/dL (4.9 mmol/L) COR 2b: In patients 30 to 75 y of age with heterozygous FH and with an LDL-C level of 100 mg/dL or higher (2.6 mmol/L) while taking maximally tolerated statin and ezetimibe therapy, the addition of a PCSK9 inhibitor may be considered. COR 1: In adults with severe hypercholesterolemia with LDL-C ≥190 mg/dL (4.9 mmol/L) without clinical ASCVD but with clinical or genetic confirmation of HeFH, additional ASCVD risk factors, or documented coronary calcification, who are on maximally tolerated statin therapy, the addition of ezetimibe, a PCSK9 mAb and/or bempedoic acid to achieve a goal of LDL-C <70 mg/dL (1.8 mmol/L) and non–HDL-C <100 mg/dL (2.4 mmol/L) is recommended to lower LDL-C and reduce ASCVD risk.
New 4.2.4.3. Severe Hypercholesterolemia With LDL-C ≥190 mg/dL (4.9 mmol/L) N/A COR 1: In adults with severe hypercholesterolemia with LDL-C ≥190 mg/dL (4.9 mmol/L) with clinical ASCVD, who are on maximally tolerated statin therapy, the addition of ezetimibe, a PCSK9 mAb, or bempedoic acid is recommended to achieve a goal of LDL-C <55 mg/dL (1.4 mmol/L) and non–HDL-C <85 mg/dL (2.2 mmol/L) to lower LDL-C and reduce ASCVD risk.
New 4.2.4.3. Severe Hypercholesterolemia With LDL-C ≥190 mg/dL (4.9 mmol/L) N/A COR 2a: In adults with severe hypercholesterolemia with or without clinical ASCVD and LDL-C ≥100 mg/dL (2.6 mmol/L) despite maximally tolerated statin with or without ezetimibe therapy, treatment with inclisiran is reasonable to lower LDL-C.
New 4.2.4.4. Severe Hypercholesterolemia With Clinical or Genetic Confirmation of HoFH N/A COR 2b: In adults with clinical or genetic confirmation of HoFH currently on maximally tolerated statin therapy, ezetimibe, and PCSK9 mAb with an LDL-C ≥100 mg/dL (2.6 mmol/L), the addition of evinacumab may be reasonable to lower LDL-C.
Revised 4.2.5. Diabetes in Adults Without Established ASCVD COR 1: In adults 40 to 75 y of age with diabetes, regardless of estimated 10-year ASCVD risk, moderate-intensity statin therapy is indicated. COR 1: In adults 40 to 75 y of age with diabetes and without clinical ASCVD, moderate-intensity statin therapy is indicated to achieve ≥30% to 49% reduction in LDL-C and a goal of LDL-C <100 mg/dL (2.6 mmol/L) and non–HDL-C <130 mg/dL (3.4 mmol/L) to reduce ASCVD risk.
Revised 4.2.5. Diabetes in Adults Without Established ASCVD COR 2a: In adults with diabetes who have multiple ASCVD risk factors, it is reasonable to prescribe high-intensity statin therapy with the aim to reduce LDL-C levels by 50% or more. COR 2a: In adults 40 to 75 y of age with diabetes who have multiple ASCVD risk factors, it is reasonable to prescribe high-intensity statin therapy to achieve ≥50% reduction in LDL-C and a goal of LDL-C <70 mg/dL (1.8 mmol/L) and non–HDL-C <100 mg/dL (2.6 mmol/L) to reduce ASCVD risk.
Revised 4.2.6. Secondary ASCVD Prevention COR 1: In patients who are 75 y of age or younger with clinical ASCVD, high-intensity statin therapy should be initiated or continued with the aim of achieving a 50% or greater reduction in LDL-C levels. COR 1: In adults with clinical ASCVD who are not at very high risk, high-intensity statin therapy should be initiated to achieve ≥50% reduction in LDL-C and a goal of LDL-C <70 mg/dL (1.8 mmol/L) and non–HDL-C <100 mg/dL to reduce the risk of recurrent ASCVD events.
New 4.2.6. Secondary ASCVD Prevention N/A COR 2a: In adults with clinical ASCVD who are not at very high risk and on maximally tolerated statin therapy, it is reasonable to add ezetimibe, a PCSK9 mAb, or bempedoic acid (selected based on the degree of LDL-C lowering needed and patient preference) to achieve a goal LDL-C <55 mg/dL (1.4 mmol/L) and non–HDL-C <85 mg/dL (2.2 mmol/L) and to reduce the risk of ASCVD events.
New 4.2.6. Secondary ASCVD Prevention N/A COR 2a: In adults with clinical ASCVD who are at very high risk and on maximally tolerated statin therapy, ezetimibe and/or a PCSK9 mAb should be added (selected based on the degree of LDL-C lowering needed and patient preference) to achieve a goal of LDL-C <55 mg/dL (1.4 mmol/L) and non–HDL-C <85 mg/dL (2.2 mmol/L) and to reduce risk of ASCVD events.
New 4.2.6. Secondary ASCVD Prevention N/A COR 2a: In adults with clinical ASCVD who are at very high risk on maximally tolerated statin therapy, it is reasonable to add bempedoic acid to a statin, with or without ezetimibe and/or PCSK9 mAb, to reach an LDL-C goal <55 mg/dL (1.4 mmol/L) and non–HDL-C <85 mg/dL (2.2 mmol/L) to reduce the risk of ASCVD events.
New 4.2.6. Secondary ASCVD Prevention N/A COR 2a: In adults with clinical ASCVD who are at very high risk and on maximally tolerated statin therapy with or without ezetimibe, it is reasonable to add inclisiran in those unable to tolerate or obtain evolocumab or alirocumab or have a strong preference for less frequent dosing to achieve an LDL-C goal <55 mg/dL (1.4 mmol/L) and non–HDL-C <85 mg/dL (2.2 mmol/L).
New 4.2.7. Management of Adults With Subclinical Coronary Atherosclerosis (Men ≥40 or Women ≥45 y) N/A COR 1: In adults with a CAC score of ≥1000 AU, treatment with LDL-C– lowering therapies with consideration of statin therapy as first-line is recommended to achieve a ≥50% reduction in LDL-C and a goal of LDL-C <55 mg/dL (1.4 mmol/L) and non–HDL-C <85 mg/dL (2.2 mmol/L).
New 4.2.7. Management of Adults With Subclinical Coronary Atherosclerosis (Men ≥40 or Women ≥45 y) N/A COR 1: In adults with a CAC score of ≥300 to 999 AU, treatment with LDL-C lowering therapies with consideration of statin therapy as first line is recommended to achieve at least a 50% lowering in LDL-C and a goal of LDL-C <70 mg/dL (1.8 mmol/L) and non–HDL-C <100 mg/dL (2.6 mmol/L).
New 4.2.7. Management of Adults With Subclinical Coronary Atherosclerosis (Men ≥40 or Women ≥45 y) N/A COR 1: In adults with a CAC score of ≥100 to 299 AU or ≥75th standardized percentile, treatment with LDL-C lowering therapies, with consideration of statins as first-line therapy, is recommended to achieve a goal LDL-C <70 mg/dL (1.8 mmol/L) and non–HDL-C <100 mg/dL (2.6 mmol/L.
New 4.2.7. Management of Adults With Subclinical Coronary Atherosclerosis (Men ≥40 or Women ≥45 y) N/A COR 2a: In adults with a CAC score of 1 to 99 AU and <75th standardized percentile, or with an incidental finding of mild CAC on noncardiac CT scan, treatment with moderate-intensity statin therapy is reasonable to achieve a ≥30% to 49% reduction in LDL-C and a goal of LDL-C <100 mg/dL (2.6 mmol/L) and non–HDL-C 130 mg/dL< (3.4 mmol/L).
New 4.2.7. Management of Adults With Subclinical Coronary Atherosclerosis (Men ≥40 or Women ≥45y) N/A COR 2a: In adults with a CAC score of ≥300 to 999 AU, it is reasonable to intensify therapy by increasing the intensity of statin therapy or, if needed, adding ezetimibe, a PCSK9 mAb or bempedoic acid to achieve a goal of LDL-C <55 mg/dL (1.4 mmol/L) and non–HDL-C <85 mg/dL (2.2 mmol/L).
New 4.2.7. Management of Adults With Subclinical Coronary Atherosclerosis (Men ≥40 or Women ≥45 y) N/A COR 2a: Among adults with no prior ASCVD who have moderate to severe incidental coronary atherosclerosis identified on noncardiac CT scans (eg, by visual estimation or a validated artificial-intelligence based algorithm), it is reasonable to initiate high-intensity statin therapy to achieve at least a ≥50% reduction in LDL-C and a goal of LDL-C <70 mg/dL (1.8 mmol/L) and non–HDL-C <100 mg/dL (2.6 mmol/L); if mild incidental CAC is found, moderate-intensity statin therapy is reasonable to achieve a >30% to 49% reduction in LDL-C and a goal LDL-C <100 mg/dL (2.6 mmol/L) and non–HDL-C goal <130 mg/dL.
New 4.2.8.1. Children and Adolescents N/A COR 2a: In children and adolescents with a clinical presentation consistent with FH, panel-based genetic testing for pathogenic/likely pathogenic rare variants for FH can be useful to guide diagnosis, cascade testing, and treatment.
New 4.2.8.4. Management of Dyslipidemia in Persons Planning Pregnancy, During Pregnancy, or While Lactating N/A COR 2a: In pregnant individuals with severe fasting hypertriglyceridemia (TG ≥500 mg/dL [5.7 mmol/L]), the use of fibrates (after the first trimester) or high-dose omega-3 ethyl esters is reasonable as an adjunct to lifestyle management to lower TG levels and reduce the risk of pancreatitis.
New 4.2.8.8. Adults With CKD—Stage 3 or Higher N/A COR 1: In adults with CKD stage 3 or higher and clinical ASCVD, LLT with high-intensity statin therapy with or without ezetimibe and/or a PCSK9 mAb is recommended to achieve a ≥50% reduction in LDL-C levels and a goal of LDL-C <55 mg/dL (1.4 mmol/L) and non–HDL-C <85 mg/dL (2.2 mmol/L) to reduce ASCVD risk.
New 4.2.8.9. Persons Living With HIV N/A COR 1: In people living with HIV aged 40 to 75 on stable combination antiretroviral therapy, statin therapy is recommended to reduce risk of a first ASCVD event and reduce the rate of coronary atherosclerosis progression.
New 4.2.8.10. Adults With Cancer or History of Cancer N/A COR 1: Adult cancer survivors with life expectancy of at least 2 y who otherwise qualify for LLT should be treated similarly to people without history of cancer to reduce the risk of ASCVD events.
New 4.2.9. Management of Hypertriglyceridemia N/A COR 1: In adults with clinical ASCVD and LDL-C ≥55 mg/dL (1.4 mmol/L) and non–HDL-C ≥85 mg/dL on maximally tolerated statin with persistently elevated TG levels ≥150 to 999 mg/dL (1.7–11.3 mmol/L), intensification of LDL-C–lowering therapy is recommended to reduce ASCVD risk.
New 4.2.9. Management of Hypertriglyceridemia N/A COR 1: In adults with familial chylomicronemia syndrome and fasting TG ≥1000 mg/dL (11.3 mmol/L), olezarsen (an apoC3 inhibitor) is recommended, as an adjunct to diet, to lower TG levels and reduce the risk of pancreatitis.
New 4.2.9. Management of Hypertriglyceridemia N/A COR 1: In adults aged 40 to 75 y without a history of ASCVD or diabetes who have persistently elevated TG levels ≥150 to 499 mg/dL (≥1.7–5.6 mmol/L), it is recommended to estimate 10-y ASCVD risk by the PREVENT equations to guide a benefit-risk discussion regarding further optimization of diet and lifestyle management as well as the potential initiation of statin therapy to reduce ASCVD risk.
New 4.2.10. Approach to Patients With Elevated Lp(a) N/A COR 1: In all individuals with elevated Lp(a) (≥125 nmol/L or ≥50 mg/dL), optimal early control of modifiable cardiovascular risk factors is recommended to reduce ASCVD risk.
New 4.2.10. Approach to Patients With Elevated Lp(a) N/A COR 1: In individuals with clinical ASCVD and elevated Lp(a) who have not achieved LDL-C and non–HDL-C treatment goals on maximally tolerated statin therapy, the addition of a PCSK9 mAb with proven cardiovascular benefit is recommended to achieve treatment goals and reduce ASCVD risk.
apoB indicates apolipoprotein B; ASCVD, atherosclerotic cardiovascular disease; CAC, coronary artery calcium; CKD, chronic kidney disease; CKM, cardiovascular-kidney-metabolic; CT, computed tomography; FH, familial hypercholesterolemia; HDL-C, high-density lipoprotein-cholesterol; HeFH, heterozygous familial hypercholesterolemia; HoFH, homozygous familial hypercholesterolemia; hsCRP, high-sensitivity C-reactive protein; LDL-C, low-density lipoprotein-cholesterol; Lp(a), lipoprotein(a); mAb, monoclonal antibody; PCSK9, proprotein convertase subtilisin/kexin type 9; PCSK9i, proprotein convertase subtilisin/kexin type 9 inhibitor; PREVENT, Predicting Risk of Cardiovascular Disease EVENTs; RDN, registered dietitian nutritionist; TC, total cholesterol; and TG, triglycerides.

Top Take-Home Messages

1.
Treat dyslipidemia earlier to reduce lifelong risk of prolonged exposure to atherogenic lipoproteins. Health behavior counseling to support lifestyle optimization should start in youth, with early consideration of pharmacotherapy in youth with familial hypercholesterolemia (FH) and in young adulthood in individuals with low-density lipoprotein cholesterol (LDL-C) ≥160 mg/dL or a strong family history of premature atherosclerotic cardiovascular disease (ASCVD).
2.
Use the more contemporary American Heart Association Predicting Risk of cardiovascular disease EVENTs (PREVENT™) equations instead of the older Pooled Cohort Equations (PCE) for 10- and 30-year risk assessment to guide lipid-lowering therapy (LLT) in primary prevention in adults aged 30 to 79 years. Use the “CPR” Model: A) Calculate 10-year ASCVD risk; B) Personalize the estimated risk to the specific patient by considering factors not included in PREVENT-ASCVD equations; and C) possibly Reclassify with selective use of coronary artery calcium (CAC) and Reassess treatment recommendations.
3.
Low-density lipoprotein (LDL)–lowering therapy can be considered in adults for primary prevention of ASCVD with a 10-year PREVENT-ASCVD risk estimate of 3% to <5% (borderline risk) and should be considered for those at 5% to <10% (intermediate risk) 10-year risk after a clinician–patient discussion.
4.
LDL-C and non–high-density lipoprotein cholesterol (HDL-C) treatment goals are back to guide LLT. Percentage reduction in LDL-C remains a priority for all individuals as well, with goal for % reduction depending on the level of ASCVD risk.
5.
Apolipoprotein B (ApoB) testing can be useful to improve risk assessment and guide therapy once LDL-C and non–HDL-C goals are met, particularly in those with elevated triglycerides (TG) (≥150 mg/dL), diabetes, or low achieved LDL-C (<70 mg/dL). ApoB measurement helps identify adults with residual elevated lipoprotein-related risk that may be underestimated by the standard lipid profile alone and may be useful in the diagnosis of specific lipid and lipoprotein disorders.
6.
Lipoprotein(a) [Lp(a)] should be measured at least once to identify those individuals at higher risk of ASCVD. It is considered as a risk-enhancing factor at levels ≥125 nmol/L (50 mg/dL), which is associated with about a 1.4-fold increased ASCVD risk, and values ≥250 nmol/L (100 mg/dL) are associated with ≥2-fold higher estimated risk. The presence of elevated Lp(a) should be an indication for more intensified LDL-C lowering and management of other risk factors.
7.
CAC scoring in men at least 40 years of age and women at least 45 years of age can improve risk assessment and guide LDL-C and non–HDL-C goals. Both the absolute amount of CAC and the corresponding standardized percentile (currently based on age, sex, and race) have prognostic importance and help to reclassify risk in adults.
8.
LDL-lowering therapy is recommended for primary prevention in adults aged 40 to 75 years with diabetes, chronic kidney disease stage 3 or 4, or human immunodeficiency virus, regardless of LDL-C level. After age 75 years, LDL-C–lowering pharmacotherapy can be considered in conjunction with lifestyle interventions to reduce ASCVD risk.
9.
In secondary prevention, a goal of LDL-C <55 mg/dL (1.4 mmol/L) and non–HDL-C <85 mg/dL (2.2 mmol/L) is recommended for those at very high risk of ASCVD events. Although a smaller number of patients with ASCVD not at very high risk have an LDL-C goal of at least <70 mg/dL, the majority of those with a history of ASCVD events will likely qualify for an LDL-C goal of <55 mg/dL.
10.
In patients with persistently elevated TG, statin therapy remains the foundation of pharmacotherapy as an adjunct to lifestyle intervention to reduce ASCVD risk. Treatment for prevention of pancreatitis may also include TG-lowering therapies, especially in individuals with TG levels ≥1000 mg/dL (11.3 mmol/L).
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