CLINICIAN GUIDE · CHOLESTEROL & CARDIOVASCULAR PREVENTION · SECTION 2 OF 3
Assess ASCVD risk, interpret additional testing, and recognize referral clues.
Document known ASCVD, prior events/procedures, diabetes, CKD, smoking, BP, and family history. Review the untreated lipid pattern when available, current medication use, and barriers to adherence.
Check for secondary contributors such as hypothyroidism, uncontrolled diabetes, kidney disease, diet, alcohol, or medications. A fasting panel is particularly useful with high triglycerides or suspected inherited disorders.[6]
The 2026 guideline uses PREVENT-ASCVD for appropriate adults without known ASCVD or subclinical atherosclerosis and with LDL-C 70–189 mg/dL. Estimate 10-year risk at ages 30–79; 30-year risk is available at ages 30–59.
Lifestyle; selected younger adults may merit medication based on LDL or 30-year risk.
Consider medication after personalized discussion.
At least moderate-intensity statin therapy is recommended.
High-intensity statin therapy is recommended.
LDL-C ≥190 is a separate treatment pathway; do not use a low calculated risk to defer therapy.[4]
Personalize estimated risk with family history, Lp(a), inflammatory disease, and reproductive history. Consider coronary artery calcium (CAC) testing when a primary-prevention treatment decision remains uncertain, particularly in men ≥40 or women ≥45.
CAC measures calcified plaque burden. A zero score does not exclude all plaque and should not automatically override a strong treatment indication. It is not the test for acute chest pain.
ApoB may clarify residual risk with high triglycerides, diabetes, or discordant lipid measures.[3][4]
Acute chest pain, focal neurologic symptoms, or suspected limb ischemia requires an acute care pathway, independent of the lipid panel.
Marked hypertriglyceridemia needs timely evaluation. At ≥500 mg/dL, assess pancreatitis risk and contributors; risk rises further around ≥1000. Severe abdominal pain or vomiting with suspected pancreatitis warrants emergency assessment.[6]
Refer to cardiology/preventive cardiology or a lipid specialist for suspected FH, premature/recurrent ASCVD, major unexplained lipid abnormalities, persistently above-goal LDL despite therapy, significant statin intolerance, or complex severe hypertriglyceridemia. FH evaluation may include genetic counseling and family screening.[5]
Adult clinician education · References reviewed October 11, 2026.