Look Earlier, Treat Earlier with the New 2026 Lipid Guidelines

Transcript generated by AI

Albert Lopez, DO 0:11

My name is Al Lopez. I am a DO and a Fellow of American College of Physicians and American Society of Preventive Cardiology. And today I'll be talking on the new 2026 multi-specialty guidelines on lipids. So these 2026 guidelines are a decade after the last guidelines, almost a decade, that were done with AHA, ACC, and also Multi-Society. What's very interesting in these guidelines today, the 2026, replaced those ones a decade ago, we finally have measurements back. So we actually have tangible measurements that we can look at and we can treat to, which I think is very apropos on the current data. The focus has been with this guideline is look earlier, treat earlier, treat aggressively to lower numbers. And by the studies, we have better outcomes if we do this. I want to remind everybody that cardiovascular disease is still the number one killer globally, not just in the United States. And these guidelines are a next move towards reducing that number one killer globally to hopefully a much lower number in the next five

Why The 2026 Guidelines Shift

Albert Lopez, DO 1:22

or 10 years. So when we look at these, the goals are now in management and looking at different things. We're looking at the management of dyslipidemia across the board, not just LDL. Like I said, the LDL goals have returned. These have included LDL, non-HDL, LP little A, and APOB as measurements to look at, but also we've added high triglycerides or hypertriglyceridemia into these guidelines. They actually discussed a greater understanding of atheroscritic cardiovascular disease over the last decade and how athogenic lipoproteins beyond LDL, which includes remnant particles, as I've mentioned, like Lp(a) and triglycerides, how affect the progression of disease. We also discuss in this implementation of newer therapeutic regimens. A lot of drugs have come out and used today, and there's a lot more, hopefully coming in the future, depending on how the studies come out. We also talk about cardiovascular risk assessment and the prevent risk score. We've had multiple over the last 10, 15 years, and none of them hit the total mark. This one is better. It's a little more inclusive on data. We'll go over it as I speak. It's better. Hopefully, we'll get even better coming up in the future. We'll discuss primary and secondary risk settings. This data in this paper included several trials: four-year trials, Odyssey outcome trials, clear outcomes trials with bempadoic acid, the reduce it trial with icosapent ethyl therapeutics. And we're looking at lifetime risk. So the prevent score gives us a 10 and 30-year risk score, but we're also looking not just at a five or 10-year risk. We're looking at lifetime risk of developing atherosclerotic disease. In addressing primary prevention, LDL goals have lowered. Now we're looking at numbers as we're measuring 70 to 189. We're looking at such severe hypercholesterolemia, heterozygous, familial hyperlipidemia, or LDLs above 190 were addressed very clearly. We include data on diabetes, clinical atherosclerosis, subclinical atherosclerosis, and again high triglycerides. So it these guidelines become pretty encompassing. You'll see me at times hesitate because this was a 125-page paper, very well done, and it was very, very inclusive.

Treat To LDL Goals Again

Albert Lopez, DO 3:49

So let's go back to lipoproteins. It did include LDL and other lipoproteins, as I've mentioned. The big conversation now is check the LDL. In no other disease do we not look and look at assessment on a measurement. In diabetes, we look at fasting sugars and A1Cs. In hypertension, we look at goals of blood pressure and systolic and diastolic blood pressures, as well as heart rate. But we haven't done this in a lipid realm. So assess and look at a lab. So do a lipid profile, treat aggressively and treat appropriately, and then relook at where your goals are. Don't just put somebody on a lipid lowering therapy and just leave it there. You have to get it to a goal with these guidelines. And I think this is very appropriate. And the data is very strong insurance showing that. Monitor those

Statins First Then Add Ons

Albert Lopez, DO 4:40

patients. First in lipid therapies is lifestyle management, which includes diet and exercise, obviously. And then for sure, statins are the baseline, the it's the cornerstone of therapy. So statins are still the most aggressive treatment, has shown the most risk reduction out of any lipid therapy currently. So statins are to be used first. We've shown in these guidelines that they're very safe, that the side effects are few and very often treatable. And if they're not and they still have myalgias or LFT abnormalities, we can do a deep dive or we can change to other treatment therapies such as ezetimibe or bempadoic acid, which does not go through muscle or using PCSK9s. So again, starting with lipid lowering therapy early, don't wait. In monitoring the lipids, we could do it fasting or non-fasting. It's preferred to do fasting because then you'll get an accurate triglyceride level. But LDLs can be directly measured. And truthfully, physiologically, we're not fasting most of the day. We're only fasting eight to 12 hours. And so physiologically, looking at a non-fasting LDL or triglyceride gives us a good hint of what your body's actually doing and the chance of insulin resistance. As I've mentioned, look at lipid lowering therapy, initiate lipid lowering therapy early after you do the initial lab value. After you treat, recheck in four to 12 weeks and adjust treatment accordingly. Once you're at baseline therapy and you're at goal with your LDL, triglycerides, and remnant particles, then again, the guidelines state that recheck again every six to 12 months, depending on the risk that patient has and what their liver functions

Non HDL And ApoB For Risk

Albert Lopez, DO 6:25

look like. I'll switch conversation to now non-HDL, which has been shown to be very voracious. I'm looking at risk beyond LDL. And this stays in the guideline as mentioned in the guidelines, and there's guideline goals, which I'll go as I converse further on in this podcast. But APOB is also there and it's used in patients with discordance of LDL. Those patients include patients with high triglycerides, obesity, insulin resistance, diabetes, metabolic syndrome, or chronic kidney disease. Why is Apo B important? Because traditionally we've used this Friedwald formula to calculate LDL. And if LDL is above a certain level, it becomes inaccurate by anywhere from 20 to 60%. So a lot of companies are using other measurements like the Samson NIH equation, or they're using the Martin Hopkins equation to better calculate LDL, but LDL can be directly measured. And APOB gives us a much more accurate measurement. In several studies, APOB has been shown to be more accurate in assessing cardiovascular risk in patients with and without cardiovascular disease. So APOB can be used when you find discordance of LDL

Screening Kids Adults And Seniors

Albert Lopez, DO 7:40

and risk. The guidelines also talk about age. So U.S. Task Force has removed pediatricians in looking at children for screening for lipids. These guidelines include children, especially children that have families that have early cardiovascular disease or risk factors like Lp(a), hetero- homozygotes, or children that may show signs of hyperlipidemia, which is not common but can occur. So screening starts at years two to four. Then the next time we start looking if those young adults or children don't have risk factors, then we look at 19-year-olds and we screen them every five years and treat accordingly. And then they address people over 70, 75. In the guidelines, they do mention that this is the time where most patients have events, is in their 70s. And so, yes, treat them accordingly and don't look at the chronological lays, looks at that individual's physiologic age. If you have a 75, 80-year-old that's still walking five miles every day, looks fantastic, looks younger than a chronic chronological age, and are actually doing a lot of things. And yes, by all means, treat that patient. They do talk about heterozygous familial hyperlipidemia, and those are individuals with LDLs above 190. Have to remember, this is not that rare. This is one in 250 individuals globally that have that are heterozygotes. So look for them. Unfortunately, 90% of patients that have LDLs above 190 are not treated and not identified. Or just people say, well, it's not really that bad. These guidelines speak to that and say, please treat these individuals aggressively. Again, start with a statin and move accordingly to get them at goal depending on what their risk enhancers are. If you do find individuals with elevated LDLs as high as 190, then cascade screening is in order. Start checking siblings and their children's and families and your family and see who else is involved because these are genetically mediated illnesses.

Lp(a) Risk Enhancers And Triglycerides

Albert Lopez, DO 9:41

They actually include lipoprotein A or Lp(a) in the guidelines as well. Lp(a) is a genetically mediated risk factor for cardiovascular disease that is independent of any other risk factor that may cause coronary disease, including LDL, diabetes, hypertension, et cetera. Lp(a) is pro-athrogenic, pro-thrombotic, and pro-inflammatory. And we think that it mediates cardiovascular disease by inflaming or adding pro making that individual more pro-thrombotic by oxidized phospholipids. Everybody should be checked once in their lifetime. And in fact, when it gets over about 200, this is equivalent to somebody that is a heterohomozygote, the higher you get. They also discuss in this guideline risk enhancers. And this is very important because very often in prior guidelines, there wasn't a lot of discussion of risk enhancers or fasting triglycerides over 150. I still hold by the original thought and many other individuals that are involved in prevention that if primary care does not look early, does not treat and initiate lipid lowering therapy, we will never reduce the number one killer globally to cardiovascular disease.

Team Based Prevention And Closing

Albert Lopez, DO 11:00

So that includes pediatrics, internal medicine and family practice. We should be screening all these guidelines. If you get in a hiccup, then consider referring to a dietitian or nutritionist, refer to a lipid specialist, refer to a exercise physiologist for exercise if you're not getting where you want to. Use the team approach that we've been doing over the last several years. Thank you.

Announcer 11:29

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