Atherosclerotic Cardiovascular Disease (ASCVD)

Most patients can have a nonfasting lipid panel for routine screening and risk assessment. Obtain a fasting panel when the patient has:

• Nonfasting triglycerides ≥400 mg/dL
• A known or suspected triglyceride metabolism disorder
• A family history of dyslipidemia or premature ASCVD

Fasting improves triglyceride assessment and can help estimate LDL-C when nonfasting triglycerides are high. Evaluate secondary causes of abnormal lipids and consider familial hypercholesterolemia (FH) when LDL-C is markedly elevated.

Measure Lp(a) at least once in adulthood, and note that it isn’t included in a standard lipid panel. Levels ≥125 nmol/L or ≥50 mg/dL indicate increased risk. These are separate unit-specific thresholds, not a fixed conversion. Use the result to refine risk discussions, address other risk factors, and guide family screening.

Consider ApoB when triglycerides are elevated (particularly ≥150 mg/dL), diabetes is present, or achieved LDL-C is low (<70 mg/dL). It can identify residual atherogenic particle burden even after LDL-C and non–HDL-C goals are met.

Use PREVENT-ASCVD for eligible adults aged 30–79 years without clinical ASCVD or subclinical atherosclerosis and with LDL-C of 70–189 mg/dL. In eligible adults aged 30–59 years, consider 30-year risk as well. Discuss risk enhancers that the calculator doesn’t capture.

The PREVENT-ASCVD estimate informs the discussion but risk enhancers can help personalize it. Examples include family history of premature ASCVD, chronic inflammatory conditions, higher risk ancestry, and reproductive history, including early menopause, preeclampsia, gestational diabetes, and preterm delivery. These may influence treatment decisions, particularly when estimated risk is borderline or intermediate.

Consider coronary artery calcium (CAC) scoring in men aged ≥40 years and women aged ≥45 years when a primary prevention treatment decision remains uncertain, particularly at borderline or intermediate risk.

• A score of zero doesn’t exclude noncalcified plaque or override every other indication for treatment.
• CAC scoring isn’t a substitute for evaluating chest pain.

New or worsening chest discomfort or other symptoms concerning for ACS require urgent assessment. For stable symptoms, select testing through a chest pain evaluation pathway based on clinical likelihood, prior disease, and patient characteristics.