34
Residual Risk After Statins and
Lifestyle Modification
Table 13. Significant Risk Indicators
Indicator
Comments
Coronary Artery
Calcium (CAC)
A CAC score ≥300 Agatston units is considered an indication
of high risk and should encourage optimal statin intensity and
goal attainment.
High-sensitivity
C-reactive protein
(hs-CRP)
An hs-CRP level ≥2.0 mg/L indicates the presence of
inflammation, which may be related to atherogenesis and
supports more intensive non-HDL-C and LDL-C lowering to
recommended goals.
Non-HDL-C,
apolipoprotein (apo)
B, or LDL particle
concentration
Discordance may occur between the LDL-C level and 1 or
more of these parameters, especially in patients with type 2
diabetes, the metabolic syndrome, or hypertriglyceridemia.
If discordance exists—i.e., the non-HDL-C, apo B, or LDL
particle concentration is higher than would be anticipated
based on the LDL-C level—further lipid-lowering treatment to
reach goal levels of non-HDL-C and apo B may be considered.
(No specific goals have been recommended for LDL particle
concentration.)
Lipoprotein(a)
[Lp(a)]
Levels of Lp(a) ≥50 mg/dL using an isoform insensitive assay is
indicative of increased ASCVD risk.
Ankle brachial index
(ABI)
Peripheral artery disease (i.e., ABI of <0.90) is one of the
strongest risk indicators of ASCVD.
LDL-C ≥160 mg/dL
and/or non-HDL-C
≥190 mg/dL
Presence of either of these in a patient at low or moderate risk
may justify a higher level of treatment.
Genetic
dyslipidemias
Patients with genetic dyslipidemias resulting in elevated
atherogenic cholesterol levels are also candidates for intensive
lowering of non-HDL-C (and LDL-C), depending on their
risk status.
Severe disturbance in
a major ASCVD risk
factor
Examples: multipack per day smoking or a strong family history
of premature CHD
Chronic kidney
disease (CKD)
Patients with stage 3B or 4 CKD (estimated glomerular
filtration rate 15–45 mL/kg/1.73 m²) are at high risk and
warrant a lower treatment goal.
