[SPEAKER_02]: Hi, everybody.
[SPEAKER_02]: I'm Ari Fish.
[SPEAKER_02]: I'm a chief resident at Mount Sinai Hospital in New York City And I'm really excited today to be joining Core IM to dive into the 2026 ACC AHA lipid guidelines that just came out I'm thrilled right now to be joined by two frontline primary care experts who can guide us a little bit more on cholesterol management based on these guidelines
[SPEAKER_02]: So, without further ado, I'd like to introduce some of our panelists.
[SPEAKER_02]: I am very excited to be joined today by Kerry and Alana.
[SPEAKER_01]: Thanks so much, Ari, for that wonderful introduction to this show.
[SPEAKER_01]: I'm Kerry Blum.
[SPEAKER_01]: I'm a primary character at Mount Sinai, work with Ari.
[SPEAKER_01]: I'm also a lipid enthusiast who spends a fair amount of time thinking about this stuff.
[SPEAKER_00]: And I'm a lot of rich man.
[SPEAKER_00]: I'm a primary care doctor and general internist at the Yale School Medicine.
[SPEAKER_00]: So happy to be here with you both.
[SPEAKER_00]: And like Carrie, I'm not a cardiologist, but I am a lipid enthusiast and also has spent some time trying to wrap my mind around the guideline.
[SPEAKER_00]: So, excited to dig in today.
[SPEAKER_02]: All right, carry Alana.
[SPEAKER_02]: Let's get going with the top 10 practice changing highlights from these new lipid guidelines.
[SPEAKER_02]: So where should we begin?
[SPEAKER_01]: All right, so let's get started with the top two practice changing highlights.
[SPEAKER_01]: I think it's helpful to start with the new framework suggested by the guidelines, which is summarized into a three-letter acronym CPR.
[SPEAKER_01]: Have you heard that one before, guys?
[SPEAKER_01]: CPR?
[SPEAKER_00]: Maybe a different CPR.
[SPEAKER_01]: Yeah, not cardio, pulmonary resuscitation.
[SPEAKER_01]: This is the one that's happening all the way at the beginning of when we're starting to think about our patient's cardiovascular health.
[SPEAKER_01]: This one stands for Calculate, Personalized, Re-classify.
[SPEAKER_01]: And essentially, describes a general approach.
[SPEAKER_01]: to identifying patient's risk and deciding management strategy based on that risk calculation.
[SPEAKER_01]: So for the C that stands for Calculate, we're using a new calculator called the Prevent score.
[SPEAKER_01]: The Prevent score has replaced the old pooled cohort equations that uses slightly different variables, but essentially most of the old ones like blood pressure, but now we're also able to add additional things like GFR and
[SPEAKER_01]: Proteinuria and geographical risk factors based on zip code.
[SPEAKER_01]: So the Prevent Score really is an improvement on the pulled cohort equations in terms of identifying a more precise risk.
[SPEAKER_01]: But then the framework goes even further to suggest that once we use the calculator we are not done, we have to really think about our patient as an individual and whether or not the calculator has done them justice.
[SPEAKER_01]: This involves primarily
[SPEAKER_01]: And then last but not least, is this reclassify step where you're putting the personalize data together with the calculator and coming to a final decision.
[SPEAKER_01]: And if you're not able to come to a clear decision, sometimes ordering additional testing such as coronary artery calcium can help be a tiebreaker when you're trying to decide whether a patient may benefit from lipid lowering therapy.
[SPEAKER_01]: So those are the first two big takeaway points.
[SPEAKER_01]: This new framework is the CPR framework and our new calculator, the prevent score, which has replaced the pulled-core and equation.
[SPEAKER_00]: All right, so point number three in our top 10 list is that we have somewhat different risk categories, then we saw under the last set of guidelines.
[SPEAKER_00]: So in the last iteration, the guidelines we were accustomed to calculating a person's tenure as CVD risk and then recommending or considering standard P based on that risk, but it was known that the pool court equations over estimated risk.
[SPEAKER_00]: and so in considering the threshold to start a statin for example, the guideline authors use a slightly higher threshold than actual risk, understanding that pulled cohort equations so they overestimated.
[SPEAKER_00]: So in this iteration, those thresholds are lowered because the prevent equations are better calibrated and really reflect actual absolute risk.
[SPEAKER_00]: just to be sure and explicit about what those thresholds are, a 10-year risk lower than 3% is considered low risk.
[SPEAKER_00]: And in general, for primary prevention, we don't necessarily need to start a certain absent a few other considerations.
[SPEAKER_00]: The next category is called borderline to those are people with a 10-year risk of 3 to 5 percent.
[SPEAKER_00]: These are people where we consider risk enhancing factors that carry a referred to, so these are the ones where we really are showing to give about that reclassification idea, and then the 5% or intermediate risk folks generally, we would recommend a statin all though we can use cackin this category to reclassify and then more than 10% is high risk.
[SPEAKER_00]: So the framework is those numbers are sort of shifted down for what we might recognize from the previous iteration of the guidelines, but are really actually meant to represent similar categories of risk.
[SPEAKER_02]: Okay, so just to recap where we are so far, we've introduced a CPR framework, calculate, personalize, and reclassify, and we also introduce that new prevent calculator, which replaces the pulled cohort equation and adds more individualized inputs, like kidney function and even social factors like zip code,
[SPEAKER_02]: We also reviewed the updated risk categories, low borderline intermediate and high risk, and how those thresholds are slightly lower than in prior guidelines, but really just better reflect true absolute risk.
[SPEAKER_02]: Okay, as think I've got it, let's keep it going.
[SPEAKER_00]: our fourth highlight is that LDL targets are back.
[SPEAKER_00]: So in the last last version of the guideline, two guidelines ago we had LDL targets, then we shifted away from them in primary prevention with a focus on starting a satin of the correct intensity and dosing, now are back to LDL targets.
[SPEAKER_00]: So what are they?
[SPEAKER_00]: So the guidelines say that for people at borderline or intermediate risk, so that 10-year prevent score of 3 to 10% basically, we would recommend an LDL target of less than 100.
[SPEAKER_00]: Along with that, there's also a recommendation to lower the LDL by about 30 to 49% from the baseline.
[SPEAKER_00]: For people at high risk, in a primary prevention category, and for some secondary prevention
[SPEAKER_00]: And then for those at very elevated risk, people, you know, for example, who's had an event so secondary prevention and have ongoing risk factors, an LDL target of less than 55 is recommended.
[SPEAKER_00]: What things I'll say about these absolute targets is that as a practice in clinicians, they're easy to kind of hang on to.
[SPEAKER_00]: Like they stick in your mind, when you're counting patients or thinking about whether we need to intensify therapy, they're just a lot easier to remember than trying to calculate the relative reduction in the LDL from their baseline and going back through the chart.
[SPEAKER_00]: So, you know, whether this is sort of the optimal approach in terms of the data and all the rest is an important question, but I think from a pragmatic standpoint, it makes a lot of sense.
[SPEAKER_01]: I love it, I agree.
[SPEAKER_01]: I mean, I think it's our approach for many other chronic diseases, like blood pressure, we create a goal, diabetes, we make an A1 seagull, and now with hyperlipidemia, we can kind of be in the same ballpark of thought process.
[SPEAKER_01]: So for our fifth practice changing highlight, I want to talk about those populations of folks for whom the calculator may not be as relevant because there are some patients that have elevated risk just by virtue of having certain comorbidities.
[SPEAKER_01]: And in this particular new iteration of the guidelines,
[SPEAKER_01]: Patients with chronic kidney disease and HIV have now been included, along with patients who have diabetes or very elevated LDL, as folks for whom lipid lowering therapy should be strongly considered, regardless of their 10-year prevent risk.
[SPEAKER_01]: Just to be a little bit more precise, patients with CKD staged three or higher, so that would be an EGFR of 60 or lower, should be on at least that intermediate risk algorithm that Elana just mentioned.
[SPEAKER_01]: You could also use the Prevent Score to identify if they may benefit from an even more intensive strategy.
[SPEAKER_01]: And then also people living with HIV.
[SPEAKER_01]: We're recently showed even in low-risk cohort to benefit from statin therapy and the reprieve trial.
[SPEAKER_01]: That's been incorporated now into the new guidelines.
[SPEAKER_01]: So I love this because it's simple.
[SPEAKER_01]: You know, we don't have to go through the calculator.
[SPEAKER_01]: So just by virtue of having either EGFR of 60 or lower, you're HIV at a minimum that would put your patient onto that intermediate risk pathway where you're targeting an LDL goal of less than 100.
[SPEAKER_00]: All right, practice changing highlight number six is lipopartine little A screening for everyone.
[SPEAKER_00]: So this, I think actually really does feel like a big shift from previous guidelines.
[SPEAKER_00]: So in the past, lipopartine little A testing was sort of optional and recommended as something we could evaluate as a risk enhancing factor.
[SPEAKER_00]: But here, we're seeing a stronger recommendation for screening for everyone.
[SPEAKER_00]: Labor meeting, little A, has some interesting features.
[SPEAKER_00]: It's largely genetically determined.
[SPEAKER_00]: It does not necessarily correlate with other lipids, so with LDL, and can really identify this other dimension of risk that can be sort of hiding in the background unless we specifically check for it.
[SPEAKER_00]: We don't at this time have
[SPEAKER_00]: medications that directly lower labor protein level A on the market although many are in development and in trials and I think we'll see treatments for labor protein level A in the next couple of years.
[SPEAKER_00]: But in the meantime our approach is really thinking about how elevated labor protein level A changes our approach to global cardiovascular risk reduction.
[SPEAKER_00]: So these are patients and whom we might think about intensification of therapy or even use of a PCS K9, which secondarily can lower labor protein level A by maybe 10 or 20%.
[SPEAKER_00]: So I think we'll really start
[SPEAKER_00]: Or during an interpreting, like a pertain little A, and it's a way in which I think the gotten to have really it sort of shifted and changed from the previous version.
[SPEAKER_01]: Absolutely.
[SPEAKER_01]: I couldn't agree more a lot at for me like over the past month have been checking a lot more lipoprotein little is and it is an important risk factor values of 250 double ones lifetime risk of experiencing an ASCVD event and values of about 125 increase ones lifetime risk by 40% compared to patients with regular LP little a level.
[SPEAKER_01]: So it's a very important risk factor that's often hiding in the background and will not be uncovered unless you check for it.
[SPEAKER_02]: So, Kerry, I'm just thinking a little bit about from a resident perspective when we have a new patient in clinic and we're getting baseline labs, do you feel like, in addition to getting hemoglobin A1C lipid panel and understanding a little bit more about their baseline with these new guidelines indicate that maybe adding an LP little A for any new patient coming into clinic would be appropriate.
[SPEAKER_01]: Generally, yes, and for me, that's kind of crept into my practice.
[SPEAKER_01]: One thing that's been annoying is for me that LP Little A takes like way longer to come back than the rest of the labs.
[SPEAKER_01]: So I've found that it's actually really important to communicate with the patient about this particular test before you order it, to let them know what you're checking for, that it's gonna take a little bit longer to come back.
[SPEAKER_01]: and how if it's elevated that may impact your outlook on their risk, because for a young patient without other risk factors, you know, if you plug them into the prevent and their 10-year risk is like 0.5%, a slightly elevated LP little A is probably not going to make me put them on a statin, but it might be helpful for them to know that that's a risk factor that they're likely to have for the rest of their life.
[SPEAKER_01]: And as they get older, maybe accumulate additional risk factors,
[SPEAKER_01]: and it may provide additional motivating factors for getting into healthy cardiovascular lifestyle.
[SPEAKER_01]: So I think in general, by default, it's a good test order.
[SPEAKER_01]: So our seventh big practice changing highlight from the new guidelines is the use of able lipoprotein B testing as an adjunct to LDL cholesterol and other measures of lipoprotein mediated risk.
[SPEAKER_01]: So as we've done for many, many decades and as we've done so far in this podcast, we've discussed LDL cholesterol as the primary biomarker that we're using to assess
[SPEAKER_01]: The sad reality is that LDL cholesterol is the one we know about best, but it's not the one that we know works the best.
[SPEAKER_01]: Apolypo protein B is more precise for an average patient, and there tends to be a certain subpopulation for whom the LDL cholesterol does not work as well, and will under risk your patient.
[SPEAKER_01]: That tends to be a patient who have high insulin resistance levels, so they may have diabetes, they may have elevated triclicerides.
[SPEAKER_01]: or an unusually low-looking LDL cholesterol.
[SPEAKER_01]: Those are folks in whom checking in APOB may help identify that subpopulation that would benefit from additional more intensive treatment.
[SPEAKER_02]: Thanks, Kerry, and just a quick reminder for those who would like to dive in a bit deeper to LP Little A and APO Lipo Protein B.
[SPEAKER_02]: There's an excellent Core IM5 Perls episode reviewing this topic
[SPEAKER_00]: All right.
[SPEAKER_00]: So our eighth practice changing highlight again gets at this idea of risk reclassification.
[SPEAKER_00]: The guidelines now identify an expanded set of reproductive risk enhancing factors.
[SPEAKER_00]: So these include things like PCOS and premature menopause which is defined as menopause younger than each 45 and also a number of conditions that can arise during pregnancy.
[SPEAKER_00]: This includes things like
[SPEAKER_00]: having a baby that's small for gestational age and gestational diabetes.
[SPEAKER_00]: So in the last probably 20 years, all these things have been recognized to confer long lasting cardiovascular disease risk.
[SPEAKER_00]: And we're increasingly thinking about identifying these in our patients.
[SPEAKER_02]: So, I think this is quite interesting and would absolutely change my management, especially if we have a new patient coming in, I don't always naturally shake to talk to them about issues that they went through during their pregnancy, especially if that was 20, 30 years prior.
[SPEAKER_01]: You know, Ari, point well taken for seeing a 65 year old woman.
[SPEAKER_01]: We're not necessarily taking a really in-depth OB history.
[SPEAKER_01]: But the way I think about this is that pregnancy involves a lot of additional physiologic stress from the standpoint of,
[SPEAKER_01]: vascular health and insulin sensitivity, and essentially gives you a little bit of a glimpse of what might happen if your patient were to undergo a stress test almost in a way, right?
[SPEAKER_01]: It's a physiologic stress test, so a lot of risk factors that may become relevant later in the patient's life could get uncovered during this very important period of time.
[SPEAKER_02]: Just to tie this together, next time I'm going to clinic, I'm really going to lean into that P of CPR, that personalized by asking if appropriate questions about reproductive history, like premature menopause, gestational diabetes, pre-eclampsia.
[SPEAKER_02]: And I think, you know, it's a good reminder for me, and that risk isn't just about what's in these calculators, but also what we can uncover during our in-depth discussions with patients.
[SPEAKER_01]: So let's move on to our ninth practice changing highlight.
[SPEAKER_01]: This is involving coronary artery calcium, also known as cac, cac scoring is something that we've known about for years, but we really are only starting to become more comfortable with in clinical practice.
[SPEAKER_01]: What is it?
[SPEAKER_01]: Well, basically, you get this score, whenever somebody has a non-con chess CT, sometimes it's a dedicated one, which is specifically looking for coronary artery calcium.
[SPEAKER_01]: And in that case, you get a score, which is called an Agustin score.
[SPEAKER_01]: But what it is is essentially a calculation of the surface area of calcium that's present in coronary arteries.
[SPEAKER_01]: And we know that if there's more calcium, there's more plaque, and if there's more plaque, there's more probability of any one of those plaques rupturing.
[SPEAKER_01]: And so quantifying the total amount of plaque can be helpful in helping to make risk more precise.
[SPEAKER_01]: The new guidelines give us more guidance than the old ones do, but it's still essentially used in the same way.
[SPEAKER_01]: So the old guidelines suggested that in patients who have either a borderline or intermediate risk prediction from the
[SPEAKER_01]: you may decide to order a CAC score as an additional data point to help make the risk estimate more precise so that patients without any CAC could potentially could stay off of lipid lowering therapy whereas the presence of coronary artery calcium generally would be an indication for therapy.
[SPEAKER_01]: But that's kind of where they stopped and the new guidelines are now expanding upon that to give us more guidelines in terms of exactly how much cacti correlate with what treatment strategy.
[SPEAKER_01]: So we still understand that having no coronary artery calcium in intermediate risk patients who are 50 or older essentially predicts no additional benefit from statin therapy, whereas once your cacti score is one or greater, you start to see the curves separate a bit
[SPEAKER_01]: The new guidelines suggest that CAC scores of a hundred or greater should be treated more intensely.
[SPEAKER_01]: The other great thing that the guidelines do is now give us a little bit more of an idea of what to do with results that we weren't expecting.
[SPEAKER_01]: So the classic case there is lung cancer screening.
[SPEAKER_01]: Occasionally you'll see a result come back with.
[SPEAKER_01]: moderate to severe visual coronary artery calcium.
[SPEAKER_01]: Those patients generally should be treated on the high-risk pathway, LDL less than 70, or if it's more of a mild, cac picture, we could probably get away with more of the intermediate risk.
[SPEAKER_01]: Strategy of less than 100.
[SPEAKER_00]: I think there's a lot of discussion about this idea of downgrading risk in people in that intermediate range and is that really valuable?
[SPEAKER_00]: Given that we know that statins are generally safe and well tolerated.
[SPEAKER_00]: But I will say that it's not unusual for people not to want to take medications, right?
[SPEAKER_00]: Like who wants to take a medication?
[SPEAKER_00]: I can totally relate to that idea.
[SPEAKER_00]: And so for a subset of people who really would like to avoid medication, this does help us, I think,
[SPEAKER_00]: reclassify which patients can safely hold off on a satin versus those that really ought to be on it.
[SPEAKER_02]: So Karen, a lot of what you say that the cat can really be used as a tiebreaker when we're looking from a perspective of primary prevention in this intermediate risk category to help us guide our
[SPEAKER_01]: Yeah, the best use case for CAC is an intermediate risk patients who are older than 45 to 50, so have had at least that amount of time to calcify if they're going to calcify when you basically need a tiebreaker, just like you said, Ari, it's a great way of putting it.
[SPEAKER_00]: All right, and then around a hour top 10 with number 10 for our practice changing highlight the role of non satin medications.
[SPEAKER_00]: So the guidelines call for the expanded use of non satin medications in primary prevention when we're trying to meet those LDL goals.
[SPEAKER_00]: And I would say even before these guidelines, I've seen increasing use of non-set medications like azidomy to try to drive down the LDL.
[SPEAKER_00]: The guidelines also talk about using other medications for primary prevention, including PCSK, 9 inhibitors, and then pedoic acid.
[SPEAKER_00]: So all these are options depending on the clinical context and the person's risk for achieving those LDL goals.
[SPEAKER_00]: I think this is really meant to refer to things like over-the-counter fish oil, over-the-counter fish oil is distinct from prescription grade, fish oil, which is highly refined, for example, icosipentethyl, which has some data around its efficacy for cardiovascular risk reduction, over-the-counter fish oil, not effective, along with a host of other kinds of supplements that patients often turn to
[SPEAKER_00]: because of claims around cardiovascular risk reduction.
[SPEAKER_00]: So we can clearly counsel a patients that these are not recommended, not effective.
[SPEAKER_00]: And of course, any over-the-counter supplement is not regulated in the same way as a pharmaceutical product by the FDA and has generally unknown risk potency, purity, and all the rest.
[SPEAKER_00]: I'll also add that I practice in a federally qualified health center or many of our patients are low income and I'm often shocked by patients who come into clinic with a plastic bag full of supplements that are really expensive and I really hold the industry accountable for the claims that they make and the way in which these supplements are marketed toward patients.
[SPEAKER_00]: These people end up spending a lot of money on things that they are hopeful will be helpful, but I don't think the evidence is their nor are the products regulated and so I really try to steer my patients away from it.
[SPEAKER_00]: Often in part because I think it's basically a waste of their money.
[SPEAKER_01]: I think that's a huge point, a lot of that a lot of patients don't really realize.
[SPEAKER_01]: If you're buying something from a pharmacy that comes in a bottle, it seems pretty legit.
[SPEAKER_01]: And I think that, you know, discussing that with patients can be a really important moment.
[SPEAKER_01]: I often will use this as sort of a way to segue back into a discussion about lifestyle, because often when there's an inversion to medication and more acceptance of supplements,
[SPEAKER_01]: amenable to conversations about healthy eating and ways that they could shift their diet around.
[SPEAKER_01]: So that may be a good direction to steer things in if questions about fish oil come up.
[SPEAKER_02]: All right, lipid lovers.
[SPEAKER_02]: Those are your top 10 practice changing highlights from the
[SPEAKER_02]: Let's do a quick recap just to close this out and go over what we learned today.
[SPEAKER_02]: So we started by learning to use the CPR framework that calculate personalize and reclassify.
[SPEAKER_02]: We calculate specifically using the new prevent calculator, which replaces the pulled cohort equation.
[SPEAKER_02]: Then we'll personalize and reclassify when appropriate.
[SPEAKER_02]: We learn that LDL targets are back and they're used in conjunction with percent LDL reduction depending on our patient risk factors to risk stratified.
[SPEAKER_02]: And remember those high risk groups who learned about today especially advanced CKD and HIV patients.
[SPEAKER_02]: We are now going to check in LP Little A once in all adults and we'll also use APOLEPO protein B when we're concerned about any type of residual risk.
[SPEAKER_02]: And don't forget about those expanded risk enhancers, especially getting a thorough reproductive history on the appropriate patients.
[SPEAKER_02]: We learn to use our cax score to help refine our decision making, but really not to override any clear risk.
[SPEAKER_02]: And finally, we're going to escalate therapy when needed, especially with non-statten medications, but we'll skip those supplements that really just don't have the evidence to back from up.
[SPEAKER_02]: So huge thanks to Core IM and to Kerry and Alana for joining, and be sure to join us for part two of this listed series where we'll walk through cases and really try to dig into exactly how to apply these guidelines in practice.
[SPEAKER_02]: Until next time,
[SPEAKER_01]: What about non-statt and drums, Elana?
[SPEAKER_00]: Perfect.
[SPEAKER_00]: Perfect segue.
[SPEAKER_01]: Dietary's something that's... What about that?