Note sull'episodio
REVISED 5 October 2026, after reading the full guideline text and its two published corrections: adds the percent-reduction goals, settles the triglyceride thresholds (apoB testing at 150 after a June correction; risk enhancer 175 nonfasting or 150 fasting), refines the very-high-risk tier, and notes that ezetimibe is no longer required before a PCSK9 antibody in clinical ASCVD. Earlier revision 30 September 2026. An approach episode on lipoprotein(a), apolipoprotein B, and the 2026 ACC/AHA dyslipidemia guideline, drawing on an ACP meeting session that applied the guideline a month after publication. It covers the cholesterol-years argument for treating earlier, the switch to the PREVENT risk calculator and why its lower numbers require recalibrated thresholds, new screening ages, and measuring lipoprotein(a) once in every adult. Numeric LDL targets are back, including below fifty-five for very high risk. Also covered: when apolipoprotein B adds information, the role of coronary calcium scoring, the SAMSON trial showing most statin intolerance is nocebo, and a mismatch between the evidence for bempedoic acid and how the guideline recommends it. This revision does two things the original did not: it reports the failure of pelacarsen in the Lp(a)HORIZON trial, announced on 4 September, which falsified the original episode's suggestion that a targeted lipoprotein(a) therapy was close; and it adds the reproductive risk-enhancing factors — menopause before forty-five, preeclampsia, gestational diabetes, gestational hypertension, preterm delivery — which the original omitted.
2026 ACC/AHA DYSLIPIDEMIA GUIDELINE — QUICK REFERENCE
Goals: % LDL reduction AND absolute goal (LDL / non-HDL / apoB, mg/dL)
Primary prevention (PREVENT 10-yr ASCVD risk)
- Low (<3%): lifestyle; no goal
- Borderline (3 to <5%): 30-49% | <100 / <130 / <90
- Intermediate (5 to <10%): 30-49%, >=50% at upper end | <100 / <130 / <90
- High (>=10%): >=50% | <70 / <100 / <70
Diabetes, age 40-75
- Standard: 30-49% | <100 / <130
- Multiple risk factors: >=50% | <70 / <100
Coronary calcium
- CAC 1-99: 30-49% | <100 / <130
- CAC 100-999: >=50% | <70 / <100 (300-999: optional <55)
- CAC >=1000: >=50% | <55 / <85
LDL >=190: absolute goals only (<100, or <70 with HeFH/risk factors/CAC, <55 with ASCVD)
Clinical ASCVD
- Not very high risk: >=50% | <70 / <100 (optional <55)
- Very high risk: >=50% | <55 / <85 / <55
(multiple major events, or 1 major event + multiple high-risk conditions)
Other thresholds
- TG risk enhancer: persistently >=175 nonfasting or >=150 fasting
- Check apoB once LDL/non-HDL goals met if TG >=150 (June 2026 correction; was >200)
- Lp(a) risk enhancer: >=125 nmol/L (>=50 mg/dL); measure once in all adults
- Clinical ASCVD: ezetimibe no longer required before a PCSK9 antibody; pick by LDL gap
- ApoB tier goals are from the guideline's Figure 1 (not verified against text)