A 65-year-old woman presents for primary-prevention cardiovascular (CV) risk assessment. She has no history of ASCVD and is not currently taking any prescription medications. Her family history is notable for premature myocardial infarction in her father at 55 years of age. She reports maintaining a healthy lifestyle, including regular physical activity and a heart-healthy diet, and is reluctant to initiate statin therapy because she feels well and is free of symptoms.
Her laboratory study results include total cholesterol level 165 mg/dL, LDL-C level 105 mg/dL, HDL-C level 60 mg/dL, triglyceride level 90 mg/dL, non–HDL-C level 110 mg/dL, and Lp(a) level 50 nmol/L.
Her calculated 10-year PREVENT-ASCVD (Predicting Risk of Cardiovascular Disease EVENTs–Atherosclerotic Cardiovascular Disease [AHA]) risk is 3.3%.
The correct answer is: A. Order a coronary artery calcium (CAC) score to further refine ASCVD risk assessment and facilitate shared decision-making regarding lipid-lowering therapy.
The 2026 ACC/AHA/Multisociety Guideline on the Management of Dyslipidemia provides a Class 1 recommendation for CAC scoring in adults without established ASCVD who are at borderline or intermediate risk (10-year PREVENT-ASCVD risk between 3% and <10%), specifically in men >40 years of age and women >45 years of age, when uncertainty exists regarding initiation of statin therapy. However, even in the absence of such uncertainty, this patient had a significant family history of premature CV disease and an LDL-C level above the recommended target for the general population (<100 mg/dL), making a discussion about lipid-lowering therapy clinically warranted.
The presence of any CAC would further strengthen the rationale for initiating lipid-lowering treatment because it provides direct evidence of subclinical atherosclerosis. Additionally, the magnitude of the CAC score can help clinicians individualize treatment goals and determine the intensity of preventive interventions based on the patient's stage of disease. The use of CAC scoring to guide clinical decision-making has been shown to improve both the initiation of and adherence to preventive strategies, including but not limited to lipid-lowering therapy, particularly among individuals with a family history of premature coronary artery disease.
This patient case quiz is part of the larger Implementing the 2026 Dyslipidemia Guidelines: From Risk Stratification to Personalized Treatment initiative, supported by Merck & Co. and Eli Lilly and Company. To visit the Learn Prevention grant page and access additional educational activities on this topic, click here.
References
- Blumenthal RS, Morris PB, Gaudino M, et al. 2026 ACC/AHA/AACVPR/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of dyslipidemia: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2026;87(19):2624-2757. doi:10.1016/j.jacc.2025.11.016
- Maron DJ, Budoff MJ, Sky JC, et al. Coronary artery calcium staging to guide preventive interventions: a proposal and call to action. JACC Adv. 2024;3(11):101287. Published 2024 Sep 24. doi:10.1016/j.jacadv.2024.101287
- Nerlekar N, Vasanthakumar SA, Whitmore K, et al. Effects of combining coronary calcium score with treatment on plaque progression in familial coronary artery disease: a randomized clinical trial. JAMA. 2025;333(16):1403-1412. doi:10.1001/jama.2025.0584
