Progress in risk assessment and management: Forecasting updates across international cholesterol guidelines

In anticipation of updates to cholesterol guidelines globally, evidence since the most recent iteration of recommendations across US and Europe for risk assessment and lipid management are reviewed. ASCVD risk estimation is at the core of determining lipid lowering goals and consideration for therapies. In primary prevention, incorporation of the PREVENT equations will be featured in updated guidelines, which will likely demarcate new, lower risk thresholds compared to the prior Pooled Cohort Equations. Additionally, the use of coronary artery calcium (CAC) improves risk estimation to inform medication allocation and LDL-C goals beyond traditional risk factor risk estimation. To achieve lower LDL-C, many adults will need multiple lipid-lowering medications. For high-risk individuals, combination therapy with low/moderate intensity statin and ezetimibe or bempedoic acid should be considered. Additionally, proprotein convertase subtilisin/kexin type 9 inhibitor (PCSK9i) therapies can be used to attain lower LDL-C in high-risk individuals, including those with clinical ASCVD or a high CAC burden. In very-high risk patients, treatment to LDL-C values as low as <30 mg/dL further reduces ASCVD risk without significant adverse events. Among individuals treated with PSCK9i therapy, those with elevated Lp(a) may have greater ASCVD risk reduction and may be a patient population that is prioritized for PCSK9i until therapies directly targeting Lp(a) are available. An ASCVD risk-based approach should be the foundation for determining LDL-C goals with consideration that multiple lipid-lowering therapies are often necessary for high and very-high risk patients who were treated to very low LDL-C in more recent randomized controlled trials.