Dyslipidemia Cpr Framework 2026

---
name: dyslipidemia-cpr-framework-2026
description: Work a primary-prevention patient through the 2026 ACC/AHA multisociety dyslipidaemia guideline CPR framework — Calculate (10-year and 30-year PREVENT-ASCVD), Classify (low / borderline / intermediate / high), Personalize (demographic, clinical, biomarker, and reproductive risk enhancers), and Reclassify (coronary artery calcium scoring where appropriate). Use when a clinician asks how to assess ASCVD risk for primary prevention, who needs a statin, borderline risk patient what to do, intermediate risk should I start a statin, risk enhancers to look for, premature family history of ASCVD how does it change risk, pregnancy-related risk factors, PCOS and cardiovascular risk. Grounded in the 2026 ACC/AHA multisociety dyslipidaemia guideline.
---

# Dyslipidaemia CPR Framework (2026 ACC/AHA)

Structured 4-step risk assessment for primary prevention: **C**alculate → **C**lassify → **P**ersonalize → **R**eclassify. The framework replaces the simpler PCE-only approach from 2018.

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## Step 1 — Calculate (10-year AND 30-year PREVENT-ASCVD)

For adults 30–79 years without ASCVD and with LDL-C 70–189 mg/dL:

- **10-year PREVENT-ASCVD** — all qualifying adults
- **30-year PREVENT-ASCVD** — also calculate in adults aged **30–59 years**, especially when 10-year risk is low (<3%)

See `prevent-ascvd-risk-calculator-interpretation` for the inputs and the calculator.

**Automatic LLT-consideration groups** (do NOT need the calculator to decide IF to treat; use it to decide intensity):

- Familial hypercholesterolaemia or **LDL-C ≥190 mg/dL** (Class 1)
- Diabetes mellitus **age 40–75** (Class 1)
- **CKD stage 3 or higher** (Class 1)
- **HIV** (Class 1)
- Older adults **>75 years** with life expectancy ≥2.5 years → moderate-intensity statin (Class 2b)

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## Step 2 — Classify by 10-year risk

| 10-year PREVENT-ASCVD | Category | Default statin recommendation (before enhancers) |
|---|---|---|
| **<3%** | **Low** | Lifestyle only (consider LLT only if LDL ≥160, 30-yr risk ≥10%, or strong family history premature ASCVD) |
| **3% to <5%** | **Borderline** | Moderate-intensity statin IF CAC >0 or multiple risk enhancers |
| **5% to <10%** | **Intermediate** | Moderate-to-high-intensity statin (Class 1); CAC can refine |
| **≥10%** | **High** | High-intensity statin (Class 1), CAC has no clear role |

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## Step 3 — Personalize with risk enhancers

**Risk enhancers tip the decision toward LLT**, especially in borderline (3–<5%) and intermediate (5–<10%) categories. Scan each row:

### Demographic & genetic enhancers

- **Family history of premature ASCVD** in a first-degree relative — male <55 y OR female <65 y
- **High-risk ancestry** — Filipino, South Asian
- **High polygenic risk score** (where available)

### Clinical enhancers

- **Chronic inflammatory disease** — rheumatoid arthritis, psoriasis, lupus, inflammatory bowel disease
- **Early stages of CKM syndrome** (cardiovascular-kidney-metabolic syndrome)
- **Women-specific reproductive risk markers:**
  - **Early menarche** (<11 years)
  - **Premature / early menopause** (<40 / <45 years)
  - **Polycystic ovarian syndrome (PCOS)**
  - **Pregnancy-related:** pre-eclampsia, preterm delivery, small-for-gestational-age, recurrent spontaneous pregnancy loss, pregnancy-induced hypertension, gestational diabetes
- **HIV** (also an automatic Class 1 LLT indication regardless of PREVENT)

### Biomarker enhancers

- **hs-CRP ≥2 mg/L on more than one occasion**
- **Lp(a) ≥125 nmol/L or ≥50 mg/dL** (see `lpa-screening-interpretation-cascade`)
- **Persistently elevated LDL-C 160–189 mg/dL**
- **ApoB ≥120 mg/dL**
- **Non-HDL-C 190–219 mg/dL**
- **Persistently elevated triglycerides** — non-fasting ≥175 mg/dL OR fasting ≥150 mg/dL

### Polygenic risk

- **High polygenic risk score** (where available)

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## Step 4 — Reclassify with coronary artery calcium (CAC)

CAC scoring is a **Class 1 recommendation** in men ≥40 OR women ≥45 years with **borderline or intermediate** PREVENT-ASCVD risk **and uncertainty about starting LLT**.

See `cac-scoring-indication-interpretation-2026` for full indications, interpretation, and how CAC modifies LDL goals.

**Quick CAC interpretation:**

| CAC score (Agatston Units) | Reclassification |
|---|---|
| **0** | Can defer LLT (consider repeat CAC in 3–7 years) unless FH / LDL ≥190 / DM / strong family history / high 30-yr risk |
| **1–99** (or <75th percentile) | **Reclassify toward LLT** — moderate-intensity statin, goal LDL <100 (non-HDL <130) |
| **100–299** (or ≥75th percentile, or moderate-to-severe incidental on non-cardiac scan) | **Reclassify toward LLT** — statin, goal LDL <70 (non-HDL <100) |
| **≥300** | Treat as high-risk — statin, goal LDL <70 (non-HDL <100), or in CAC ≥1000 push to LDL <55 (non-HDL <85) |

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## Step 5 — Shared decision-making and action

Having completed C-P-R, the final step is a **patient-centred shared decision-making conversation** (Class 1 for individualised risk and benefit discussion).

Key discussion points:

- Baseline lipid profile and category
- 10-year and 30-year PREVENT-ASCVD estimates (in easy-to-understand terms)
- Risk enhancers present / absent
- CAC result if performed
- Benefits of LLT: expected LDL reduction, expected ASCVD risk reduction, cost
- Risks of LLT: statin-associated muscle symptoms, slight increase in new-onset diabetes (particularly if other DM risk factors), monitoring requirements
- Lifestyle optimisation as the shared cornerstone

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## Guardrails

- **The CPR framework is NOT about running every patient through every step** — low-risk patients with no enhancers finish at Step 2 with lifestyle; automatic Class-1 groups skip Step 2–4 for the "whether" decision and use the framework only for intensity
- **Enhancers are additive but qualitative** — the guideline does not provide a "count ≥N → treat" rule. Treat the pattern, not a numerical threshold
- **Reproductive risk history is often missed** — early menarche, PCOS, preeclampsia, GDM, early menopause each independently raise ASCVD risk and are frequently absent from a cardiac risk history. Ask specifically
- **High-risk ancestry (Filipino, South Asian) is a Class 1 enhancer** — South Asian patients in particular may have under-estimated risk on standard scores
- **CAC = 0 with FH or LDL ≥190 is NOT reassuring** — FH drives early high LDL exposure that CAC does not reflect at a single point. Still treat
- **CAC = 0 does not permanently exempt from LLT** — repeat in 3–7 years. CAC progression over time is itself a risk signal
- **CAC = 0 with current cigarette smoking, DM, age >40, strong family history premature ASCVD, or severe hypercholesterolaemia (LDL >190)** → the "defer LLT" option is weaker; shared decision still leans toward LLT
- **30-year risk matters in young adults** — a 10-year risk of 2% in a 35-year-old with 30-year risk of 12% is not reassurance; it is a trigger for LLT consideration (Class 2a)
- **A single borderline hs-CRP is not an enhancer** — the guideline specifies "≥2 mg/L on more than one occasion"
- **Lp(a) is a lifetime measurement** — a normal Lp(a) once is sufficient and does not need repeating; an elevated Lp(a) is persistent and warrants cascade screening of first-degree relatives

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## Related MD2SKILL skills

- `prevent-ascvd-risk-calculator-interpretation` — the Step 1 risk calculation
- `cac-scoring-indication-interpretation-2026` — the Step 4 reclassification tool
- `dyslipidemia-ldl-treatment-goals-2026` — the goals after the category is set
- `lpa-screening-interpretation-cascade` — Lp(a) as a biomarker enhancer
- `bemdec-prescribing-guide` — bempedoic acid, if non-statin add-on is needed

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## Sources

**Primary:** 2026 ACC/AHA/AACVPR/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Multisociety Guideline on the Management of Dyslipidaemia.

**Review used for extraction:** Abramov D et al. **Primary Prevention of Dyslipidemia: 10 Practice-Changing Takeaways from the 2026 ACC/AHA Multisociety Guideline.** *Current Atherosclerosis Reports.* 2026;28:63. DOI: 10.1007/s11883-026-01437-9.