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cardio.lipid.core.v1

Dyslipidemia / lipid management

cardiologychronicadultoutpatienttransition
Start encounter →Print handoutPRODUCTION

4-step intensity ladder (high-intensity statin → ezetimibe → PCSK9i/inclisiran → bempedoic/evinacumab) + phenotype matrix axis; outpatient + transition setting playbooks; six severity triggers including severe TG, FH pattern, ASCVD recurrence, SAMS, rhabdo, and elevated Lp(a). No zone-based action plan included — lipid management is not symptom-based for self-monitoring (per task brief: skip). DEPTH-PASS-2 2026-05-16 (shard-07-cardio-chronic, golden-template-mirrored on cardio.htn.core.v1) added: (1) co-located _design-brief.md + _research-bundle.md per §5.5 items 1+2 (19 verified PMIDs live-fetched via PubMed MCP, named trials + effect sizes + 95% CI, retrieval-dated 2026-05-16, Consensus→WebSearch fallback logged); design_brief: repointed from the scaffold-stub package brief to src/lib/dossiers/cardio.lipid.core.v1._design-brief.md. (2) cardio.lipid.core.v1 differentials+ros+finding-lrs seed files (11 differentials w/ cohort-anchored priors — dyslipidaemia cause/phenotype partition: polygenic/HeFH/HoFH/FCH/severe-HTG/Lp(a)/secondary + true-vs-nocebo intolerance; 13 ROS; 31 LR rows (every row carries both LR+ and LR− → 23 LR+ >1 / 23 LR− <1, ≥15 each); 3 conditional-dependency rules; T_test≈1%/T_treat≈10%). (3) 2nd regimen axis lipid_phenotype_matrix (drug × risk-tier/LDL-threshold/phenotype gating as data). (4) RxCUI bugs fixed (11 of 16): ezetimibe 38454→341248, evolocumab 1551303→1665684, alirocumab 1551305→1659152, bempedoic 2383728→2282403, icosapent 1597777→1304974 (aligned to DrugEffectProfile registry, validator IN:OK); fenofibrate 33688→8703, gemfibrozil 5001→4719, niacin 42954→7393, colesevelam 351264→141626, inclisiran 2471072→2588243, evinacumab 2472090→2478335 (live-RxNav-verified IN-level; prior CUIs were wrong-drug or NOT_FOUND); setting-playbook drug_action CUIs repointed too. (5) Guideline content refresh 2018→2026: primary_guideline rewritten to 2026 ACC/AHA Dyslipidemia (PMID 41824590/41824552, retires 2018, absorbs 2022 ECDP); risk-tier LDL goals <55/<70/<100 + non-HDL <85 encoded; PREVENT for primary prevention; icosapent ethyl repositioned for residual-TG risk; Lp(a) once-in-lifetime + investigational pelacarsen routing; statin-intolerance true-vs-nocebo (SAMSON/GAUSS-3) added; evidence.pmids 6→19, last_reconciled 2026-04-10→2026-05-16. PREVENT calculator (race-free, replaces Pooled Cohort) referenced in manifest; not yet a clinical-tools-registry entry — flagged for P0 orphan-calculator sweep (owned by UI-fix terminal, not this depth shard). No Lp(a)-specific calculator yet — no approved Lp(a)-lowering drug (pelacarsen Lp(a)HORIZON / olpasiran OCEAN(a) ongoing); add when CVOTs read out. DEPTH-PASS-3 2026-05-26 (lane-E): +NMA (Naci CCQO 2013 + CTT framing) +USPSTF (Statin B 2022 PMID 35997723) +Cochrane (Taylor CD004816 PMID 23440795) +ICER (Kazi PCSK9i JAMA 2017 PMID 28829863) +decision thresholds (PREVENT 7.5/10/20%) +Pauker-Kassirer anchor (PMID 7366635), side-car at cardio.lipid.core.v1._depth-pass-3.md.

Entry points (5)

  • lab_abnormality
    LDL-C above target for risk class ACC/AHA 2018 Grundy
    ldl_elevated
  • lab_abnormality
    Lp(a) ≥50 mg/dL (≥125 nmol/L) — universal screen ACC/AHA 2018
    lpa_elevated
  • problem_list
    Established ASCVD — secondary prevention ACC/AHA 2018
    ascvd_secondary_prevention
  • problem_list
    Familial hypercholesterolemia / LDL ≥190 / HoFH ACC/AHA 2018 Grundy
    fh_or_extreme_ldl
  • problem_list
    TG ≥500 → pancreatitis prevention; ≥1000 chylomicronemia ESC/EAS 2019
    severe_hypertriglyceridemia

Required inputs (13)

  • agerequired
    demographic • used at CONTEXT
    PREVENT calculator + statin tolerability ACC/AHA 2018
  • ldlrequired
    lab • used at TREATMENT
    Primary target across all risk classes ACC/AHA 2018 Grundy
  • hdl
    lab • used at INITIAL_WORKUP
    Component of risk equation; not a treatment target CTT Baigent 2010
  • triglyceridesrequired
    lab • used at INITIAL_WORKUP
    TG-driven phenotype + pancreatitis risk ESC/EAS 2019
  • apob
    lab • used at INITIAL_WORKUP
    Residual risk + non-HDL marker ESC/EAS 2019
  • lpa
    lab • used at INITIAL_WORKUP
    2026 universal Lp(a) Class I (once)
  • creatininerequired
    lab • used at CONTEXT
    Statin / fibrate dose adjustment + ezetimibe + bempedoic acid renal ACC/AHA 2018
  • lft
    lab • used at CONTEXT
    Baseline LFT before statin / bempedoic acid ACC/AHA 2018
  • a1c
    lab • used at INITIAL_WORKUP
    DM modifies risk; statin-induced new-onset DM monitoring JUPITER Ridker 2008
  • tsh
    lab • used at INITIAL_WORKUP
    Hypothyroidism reversible secondary lipid driver ESC/EAS 2019
  • ascvd_statusrequired
    history • used at CONTEXT
    Primary vs secondary prevention drives target ACC/AHA 2018 Grundy
  • fh_or_extreme_ldl
    history • used at CONTEXT
    FH suspicion if LDL ≥190; HoFH triggers evinacumab ACC/AHA 2018
  • current_meds
    medication • used at CONTEXT
    Existing statin intensity, drug-drug (simvastatin + macrolide / CCB) ACC/AHA 2018

12-phase flow (8)

  1. 1FRAME
    Confirm chronic management; very-high-risk secondary prevention triggers <55 mg/dL target ESC/EAS 2019
    inputs: ascvd_status
    advance: risk class assigned
  2. 2ENTRY
    Capture trigger (lipid abnormality / ASCVD diagnosis / family history) ACC/AHA 2018
    inputs: age
    advance: entry trigger captured
  3. 3CONTEXT
    ASCVD comorbidities, DM, CKD, FH, current meds, lifestyle ACC/AHA 2018 Grundy
    inputs: ascvd_status, creatinine, current_meds
    advance: context complete
  4. 4INITIAL_WORKUP
    Fasting or non-fasting lipid panel, ApoB, Lp(a) (once), A1c, TSH, LFT, BMP ESC/EAS 2019
    inputs: ldl, triglycerides, apob, lpa, a1c, tsh
    actions: panel.lipid, panel.glucose_a1c, panel.thyroid, panel.renal, panel.lft
    advance: baseline workup documented
  5. 5RISK_STRATIFICATION
    PREVENT calculator (primary) → borderline / intermediate / high; secondary prevention → high vs very-high; CAC for borderline / intermediate reclassification ACC/AHA 2018
    inputs: age, ldl
    advance: risk class assigned
  6. 6TREATMENT
    Lifestyle + statin intensity by class; IF goal not met → ezetimibe IMPROVE-IT Cannon 2015 → PCSK9i FOURIER Sabatine 2017 / ODYSSEY Schwartz 2018 or inclisiran → bempedoic acid CLEAR Nissen 2023; HoFH → evinacumab; severe TG → icosapent ethyl + fibrate; ACC/AHA 2018
    inputs: ldl, triglycerides, creatinine
    advance: goal-tolerated regimen and adjuncts initiated
  7. 7MONITORING
    Lipid panel 4–12 wks after change → q3–12 mo at goal; LFT/CK only if symptomatic; A1c q3–6 mo on statin in DM-borderline ACC/AHA 2018
    inputs: ldl
    actions: panel.lipid
    advance: monitoring schedule documented
  8. 8FOLLOWUP
    Cascade screen for FH; vaccinations; ASCVD bundle (BP, A1c, antithrombotic per CCD/STEMI engines) ACC/AHA 2018
    advance: long-term + family-screen plan documented