Dyslipidaemia CPR Framework (2026 ACC/AHA)

Structured 4-step risk assessment for primary prevention: Calculate → Classify → Personalize → Reclassify. 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.