A 61-year-old man with type 2 diabetes mellitus (DM), stage 3a chronic kidney disease (CKD), and hypertension presents for primary-prevention follow-up. He has no clinical ASCVD and is taking atorvastatin 40 mg QD.
His current lipid profile values include LDL-C level 82 mg/dL, non–HDL-C level 112 mg/dL, and apolipoprotein B (apo B) level 94 mg/dL.
The correct answer is: A. Add nonstatin therapy because of high patient risk and persistent elevation of atherogenic particle burden.
Residual atherosclerotic risk can remain despite an apparently acceptable LDL-C level. In patients with DM and CKD, apo B and non–HDL-C levels help quantify the burden of circulating atherogenic particles. The apo B level of 94 mg/dL indicates persistent particle burden and supports treatment intensification in the context of his high-risk clinical profile. Apo B levels reflect the number of atherogenic lipoprotein particles. Persistent elevation despite statin therapy reveals residual particle burden and supports intensification.
An LDL-C level <100 mg/dL is not necessarily adequate for a patient with DM, CKD, and persistent apo B level elevation. A single LDL-C threshold can underestimate residual risk. DM is an important high-risk condition but does not identify the laboratory finding that most directly demonstrates residual lipid-related risk despite treatment. Age contributes to global risk but does not, by itself, demonstrate inadequately treated atherogenic lipoprotein burden.
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
- Sniderman AD, Thanassoulis G, Glavinovic T, et al. Apolipoprotein B particles and cardiovascular disease: a narrative review. JAMA Cardiol. 2019;4(12):1287-1295. doi:10.1001/jamacardio.2019.3780
- Sniderman AD, Dufresne L, Pencina KM, Bilgic S, Thanassoulis G, Pencina MJ. Discordance among apoB, non-high-density lipoprotein cholesterol, and triglycerides: implications for cardiovascular prevention. Eur Heart J. 2024;45(27):2410-2418. doi:10.1093/eurheartj/ehae258
