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Introduction
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. 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–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)
(>200 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.
