Transcript: HelixTalk #198 - Lp(a), ApoB, and CAC: Navigating the 2026 Dyslipidemia Guideline Alphabet Soup
Episode ID: 233
Generated: 2026-09-24 13:38:30
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Speaker 1: Welcome to HelixTalk, an educational podcast for healthcare students and providers covering real-life clinical pearls, professional pharmacy topics, and drug therapy discussions.

Speaker 2: This podcast is provided by pharmacists and faculty members at Rosalind Franklin University College of Pharmacy.

Speaker 1: This podcast contains general information for educational purposes only. This is not professional advice and should not be used in lieu of obtaining advice from a qualified healthcare provider.

Speaker 2: And now, on to the show.

Dr. Sean Kane: Welcome to HelixTalk episode 198. I'm your co-host Dr. Kane.

Dr. Khyati Patel: And I'm Dr. Patel. And the title of today's episode is Lp(a), ApoB, and CAC: Navigating the 2026 Dyslipidemia Guideline Alphabet Soup.

Dr. Sean Kane: So Dr. Patel, I'm sure you've heard that there are some new lipid guidelines that were recently published and we're going to be talking about those from the ACC-AHA. They're the 2026 guidelines on the management of dyslipidemia today.

Dr. Khyati Patel: You know, this episode could not have come earlier enough, Dr. Kane, because I could not escape hearing about these guidelines. It's been everywhere. So we are so happy to finally talk about it. But before we jump into the guidelines and how they were updated and stuff, maybe we can present a quick clinical case that we can apply the findings or the updates of these guidelines. Let's say you have Rodney, who is a 54-year-old male. Past medical history is significant for controlled hypertension, newly diagnosed with type 2 diabetes, and obesity with a BMI of 35. His antihypertensive and antihyperglycemic therapies are optimized, but overall ASCVD risk reduction still needs to be addressed. The most recent fasting lipid panel shows total cholesterol of 198, LDL of 128, triglycerides of 201, and HDL of 27. So we're kind of looking at that mixed dyslipidemia picture here. His family history is significant for mother having a type 2 diabetes and hypertension and the father having hypertension, heart failure, and an MI at the age of 47. His dietary habits are improving because he is consulting a dietitian and he has started to work out, aerobic activity. Denies any tobacco, alcohol, or substance use. And so really the big question is if you have a patient like Rodney in front of you, how would you calculate the ASCVD risk and what's the best approach to manage that risk?

Dr. Sean Kane: Yeah, and really the intent of the 2026 AHA ACC guidelines is to kind of help answer some of those questions. So importantly, this retires and replaces the 2018 guidelines. So really not that old, but old enough that probably we needed an update. And it should be noted that these are the dyslipidemia guidelines, not the blood cholesterol guidelines. So focusing on, you know, abnormalities of the lipid profile overall. And we do have a link to the reference in the show notes. And just like all of our guideline updates for HelixTalk, we're not going to cover all 123 pages of the guidelines. We've kind of picked out the most important or salient points. But if you want to dive into it, you can go to our show notes at helixtalk.com. Again, this is episode 198 and kind of get as deep as you want to go on those guidelines.

Dr. Khyati Patel: Yeah, and then for clinician use, they also have that guidelines at a glance link that we would put in our show note as well. Really it kind of highlights those top 10 recommendations that stem out versus this 123 page document is really detailed. But the overall strategy, Dr. Kane, the guidelines are embracing is earlier and lower for longer. So start treatment early, lower the LDL as much as possible, and then continue the treatment as long as possible. Lifelong screening has been emphasized, you know, starting from pediatric years. Intensive LDL goals, so yes, the goals are back. And then earlier initiation of treatment and ongoing monitoring as well as titration, appropriate titration.

Dr. Sean Kane: So along the lines of kind of screening and earlier treatment is a newer recommendation related to how we're going to assess someone's 10-year risk of a future ASCVD event. So back in 2013, we had the pooled cohort equations to estimate the 10-year ASCVD risk. And in 2023, a newer equation was published called the PREVENT ASCVD equation. And this was recommended by the new hypertension guidelines that we covered back in episode 193. And again, same organization, ACC-AHA, not surprising that they're also embracing this for the dyslipidemia guidelines as well.

Dr. Khyati Patel: And then kind of differences from that pooled cohort equation to this PREVENT calculator is that the age starts early. So instead of 40, it starts at age of 30. It goes a little bit beyond that, you know, 75 years of age, so you could have patient up to 79 years of age. The biggest change here is that it does not include race as a covariate. And that was probably a bigger talking point when we were talking about race-based medicine in general. However, it does include new metrics such as, you know, putting a BMI, if you have that available, putting patient's eGFR, because they want to accurately capture those CKM, the cardio-kidney-metabolic issues that are coming in. So it kind of captures that better here.

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Dr. Sean Kane: And there are also optional metrics. So optional meaning that if you have these, it improves the quality of the prediction equation slightly, but if you don't have them, you don't necessarily need them. And those three optional ones are a social deprivation index, which is based on the patient's zip code. And that relates to like within that zip code, what is the typical income, the typical education level, things like that. Also an A1C and a urine albumin-creatinine ratio. So again, if you have those, you can add those in as part of the prediction, but if you don't have those, you don't need them to generate a 10-year or even a 30-year ASCVD risk.

Dr. Khyati Patel: Besides these differences, I think there is another very important difference that PREVENT calculator brings compared to the pooled cohort equation.

Dr. Sean Kane: Yeah, so, and we'll talk about the thresholds later, but in the dyslipidemia guidelines, they say that the pooled cohort equation overestimated risk by about 40 to 50% on average. Because of that, we have newer, lower thresholds because the PREVENT equation is going to be 40 to 50% lower on average in terms of that 10-year ASCVD risk. I feel like this was kind of like an oops, like our previous equation we used for more than a decade overestimated by 50% and we kind of didn't talk much about that. I'm a little bit surprised this wasn't a bigger deal. I guess it's good that we're using a more accurate equation, but it does kind of indicate or highlight the fact that these are truly estimates, like very rough estimates. It's not like if you have someone at 7.4% ASCVD risk that that's dramatically different than a 7.6% ASCVD risk because in truth, these are very rough estimates to kind of guide decision-making processes, not to be very black and white.

Dr. Khyati Patel: And all the while the additional things such as BMI and A1C, you know, that information can be incorporated, know that some of the other risk factors are not included, such as a pertinent family history of premature ASCVD. So you the point goes to say is that these are really rough estimates and then patient's risk assessment should involve looking at those risk factors, the risk enhancing factors, etc.

Dr. Sean Kane: Yeah, so given that the older 7.5% threshold that we had historically was an overestimator, inflated because it used the pooled cohort equation, using the new PREVENT equation, we now have new thresholds. And the new thresholds are 3, 5, and 10%. So if a patient's 10-year ASCVD risk is less than 3%, we call that low risk. Between 3 and 5%, it's a borderline risk. Between 5 and 10%, it's an intermediate risk. And then 10% or greater is a high risk patient.

Dr. Khyati Patel: Dr. Kane, I'm not sure if you came up with this mnemonic, but there is an easy way to remember the 3, 5, and the 10% threshold.

Dr. Sean Kane: So AI helped me with this one to be honest with you, but the mnemonic aid is triangle hand bowling. So triangle, there's three sides to a triangle, and that is the initial threshold of between low risk and borderline risk. There's five fingers on your hand, so that is the threshold between borderline and intermediate risk. And then at 10%, there's 10 bowling pins. So 3, 5, 10, triangle, hand, bowling. Those are the three thresholds between low, borderline, intermediate, and then high risk.

Dr. Khyati Patel: And this is where the recommendations in the guidelines kind of come in at the kind of language they have used. So like if the risk is the borderline risk, which is 3 to less than 5%, then the statin or the LDL lowering therapy quote unquote can be considered. But if it's the intermediate, which is 5 to less than 10%, then it should be considered.

Dr. Sean Kane: And if we go back to the pooled cohort equations from 2013 where our main threshold was 7.5%, and I understand that between 5 and 7.5% it was kind of that can be considered threshold, but if you're picking the 7.5% from the older guidelines, that is now the 5% from the newer guidelines. So historically that 7.5% treatment threshold is now a 5% treatment threshold using the PREVENT equation.

Dr. Khyati Patel: So that's a drastic change. The other change that is that the goals are back again. NLA kind of stuck with the goals the whole time. AHA ACC kind of steered away and now we are back to the goals again.

Dr. Sean Kane: Yeah, so really if you think about what our goals are for most patients, there's basically three tiers. So we have a moderate intensity tier, we have a high intensity tier, and then we have like an extra high intensity tier, I guess. So the first tier is people who you're trying to decrease their LDL between 30 and 49% and their LDL goal is going to be less than 100. And the way that you would do this primarily is using a moderate intensity statin.

Dr. Khyati Patel: So these are going to be individuals whose PREVENT ASCVD score is that less than 10%. They don't have the family history of dyslipidemia or additional ASCVD risk factors. And we'll talk about the CAC score, but the CAC score is between 1 to 99.

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Dr. Sean Kane: So then for a higher risk patient population, we would want their LDL to drop by at least 50%. And for those patients, and these are all like higher risk people, so for the first tier, it's an LDL goal less than 70, which we've kind of always had that. And then for the extra high risk patients, they have an LDL goal of less than 5