A 52-year-old woman with no prior ASCVD presents for primary-prevention assessment. She has treated hypertension and BMI 31.0. Her father experienced a myocardial infarction at 48 years of age. She does not smoke and does not have diabetes mellitus.
Laboratory study results include LDL-C level 146 mg/dL, apolipoprotein B level 122 mg/dL, Lp(a) level 112 nmol/L, and hsCRP level 3.6 mg/L. Her 10-year cardiovascular (CV) risk estimated with PREVENT (Predicting Risk of Cardiovascular Disease EVENTs [AHA]) is 6%.
The correct answer is: C. Integrate the PREVENT estimate with her risk-enhancing factors and, after shared decision-making (SDM), initiate statin therapy.
The PREVENT risk score provides a quantitative estimate of absolute CV risk, but the estimate is not the entire decision. This patient had several clinically important risk enhancers: premature family history, obesity, elevated apo B level, elevated Lp(a) level, and hs-CRP level >2 mg/L. Together, these findings shift the decision toward pharmacologic LDL-C level lowering in addition to intensive lifestyle treatment. SDM should address expected benefit, treatment burden, preferences, and follow-up. A comprehensive assessment supports statin initiation because the calculated risk is reinforced by several risk-enhancing features.
Lifestyle intervention is essential but does not adequately address the aggregate risk signaled by premature family history and multiple biomarker values. The PREVENT percentage should not be used as an isolated automatic trigger. The decision should integrate the risk estimate with enhancers and patient preferences. Routine coronary CT angiography is not required for preventive lipid decisions. If uncertainty persists, coronary artery calcium scoring—not CT angiography—may be considered selectively.
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
- Khan SS, Matsushita K, Sang Y, et al. Development and validation of the American Heart Association's PREVENT equations. Circulation. 2024;149(6):430-449. doi:10.1161/CIRCULATIONAHA.123.067626
- Khan SS, Ndumele CE, Bhave N, et al. Use of predicted risk and expected benefit to guide decision-making in cardiovascular-kidney-metabolic syndrome for the primary prevention of cardiovascular disease: a scientific statement from the American Heart Association and American College of Cardiology. J Am Coll Cardiol. 2026;88(5):589-612. doi:10.1016/j.jacc.2026.05.007
