Statin Protocol | Evidence-Based Cholesterol Management

Why Testing Matters Even When LDL is High:

While LDL cholesterol contributes to atherosclerosis, your actual cardiovascular event risk depends on multiple factors—age, blood pressure, diabetes, smoking, family history, and most importantly, actual plaque burden in your arteries. Modern tools allow us to measure plaque directly (CAC scoring), assess particle number (apoB), and identify genetic risk factors (Lp(a)). This personalized approach helps us avoid overtreatment in low-plaque, low-risk individuals while intensifying therapy where risk is truly elevated. Risk assessment using contemporary tools like the AHA PREVENT calculator guides decisions far better than LDL alone.

Step 1: Baseline Assessment & Initial Testing

Calculate 10-year cardiovascular risk using AHA PREVENT calculator (ages 40-79). Combined with testing below, this guides treatment decisions.

Order these labs:

Lipid panel (LDL-C, HDL-C, triglycerides)
ApoB (preferred particle number marker)
Lp(a) (once)
hs-CRP
A1c / fasting glucose
TSH
ALT / AST / eGFR
Blood pressure and waist/height ratio
Homocysteine (optional)

Any of these risk factors present?

Proceed to Step 2 if ANY of the following:

ApoB ≥ 90 mg/dL (higher risk; < 80 mg/dL = optimal)
Lp(a) ≥ 125 nmol/L (or ≥ 50 mg/dL)
hs-CRP ≥ 2 mg/L on ≥ 2 occasions, ≥ 2 weeks apart
A1c ≥ 5.7% or fasting glucose ≥ 100 mg/dL
Autoimmune/inflammatory disease or strong family history of premature ASCVD

If NONE apply and ApoB < 80 mg/dL and LDL-C < 130 mg/dL → skip to Step 4 (lifestyle focus)

↓ Choose ONE path based on your risk assessment results ↓

YES - High Risk

(If low risk, skip to Step 4 below)

Step 2: Secondary Testing / Imaging

If triggered from Step 1 or borderline results:

Coronary Artery Calcium (CAC) score
Review metabolic/liver/thyroid labs for treatable causes

High-risk criteria met?

CAC Scoring Decision Guide:

CAC = 0 → Reasonable to defer statin; focus on lifestyle; reassess in 3-5 years (earlier if risk increases)
CAC 1-99 (especially age ≥55) → Favors statin; consider moderate-intensity therapy with shared decision-making
CAC ≥ 100 or ≥ 75th percentile → Initiate statin; proceed to Step 3

Also proceed to Step 3 if: Persistent metabolic abnormality after correction, or ApoB ≥ 90 mg/dL despite lifestyle optimization

YES - Therapy Indicated

Step 3: Therapy Consideration (Statin Decision)

If you reached this step, lipid-lowering therapy is recommended.

Shared Decision-Making: Discuss absolute risk reduction, expected benefits, potential side effects, and patient preferences with your clinician. Treatment decisions should be individualized based on your values, risk tolerance, and overall health goals.

Treatment approach:

First-line: Statin therapy (low-dose pravastatin or rosuvastatin; consider SLCO1B1 genotyping to guide agent selection and minimize side effects)
If statins contraindicated or not tolerated: Non-statin alternatives such as ezetimibe or bempedoic acid may be considered
Re-check ApoB, LDL-C, liver enzymes, and CK in 3 months
If targets unmet (ApoB ≥ 80-90 mg/dL or LDL-C > 70 mg/dL) and high risk confirmed → consider PCSK9 inhibitor or inclisiran

— OR —

NO - Low Risk

(High-risk patients follow Steps 2-3 above)

Step 4: Lifestyle First & Monitoring

For patients in safe range (Step 1 passed and CAC = 0):

Mediterranean/plant-centric diet
Strength + aerobic training
BP < 130/80 mmHg (if tolerated/individualized)
Sleep > 7 hours, avoid smoking

Monitoring schedule:

Re-check lipid panel + ApoB + hs-CRP every 3-5 years
Repeat CAC in 3-5 years (or sooner if new risk factors arise)

Testing-First Cholesterol Management Protocol

Step 1: Baseline Assessment & Initial Testing

Step 2: Secondary Testing / Imaging

Step 3: Therapy Consideration (Statin Decision)

Step 4: Lifestyle First & Monitoring