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cardio.lipid.core.v1PRODUCTION
cardio.lipid.core.v1

Dyslipidemia / lipid management

cardiologychronicadult
Hard-required inputs
0 / 5
Care setting:

Encounter flow

8/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm chronic management; very-high-risk secondary prevention triggers <55 mg/dL target ESC/EAS 2019

Inputs
1
Actions
0
Advance rule
Set
Advance when

risk class assigned

Patient inputs (13)

PREVENT calculator + statin tolerability ACC/AHA 2018

Statin / fibrate dose adjustment + ezetimibe + bempedoic acid renal ACC/AHA 2018

Primary vs secondary prevention drives target ACC/AHA 2018 Grundy

TG-driven phenotype + pancreatitis risk ESC/EAS 2019

Primary target across all risk classes ACC/AHA 2018 Grundy

Baseline LFT before statin / bempedoic acid ACC/AHA 2018

FH suspicion if LDL ≥190; HoFH triggers evinacumab ACC/AHA 2018

Existing statin intensity, drug-drug (simvastatin + macrolide / CCB) ACC/AHA 2018

Component of risk equation; not a treatment target CTT Baigent 2010

Residual risk + non-HDL marker ESC/EAS 2019

2026 universal Lp(a) Class I (once)

DM modifies risk; statin-induced new-onset DM monitoring JUPITER Ridker 2008

Hypothyroidism reversible secondary lipid driver ESC/EAS 2019

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (6)

6 need judgement
  • informationallife_threateningrhabdomyolysis_on_statin
    CK >10x ULN with muscle symptoms +/- renal injury (ACC/AHA 2018)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresevere_hypertriglyceridemia_pancreatitis
    TG ≥1000 mg/dL — chylomicronemia syndrome / pancreatitis risk (ESC/EAS 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverefh_pattern
    LDL ≥190 untreated OR clinical FH (DLCN ≥6) OR genetic LDLR/APOB/PCSK9 variant (ACC/AHA 2018)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereascvd_recurrence_on_statin
    New ASCVD event on max-tolerated statin (ACC 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatelp_a_high_with_ascvd
    Lp(a) ≥125 nmol/L (≥50 mg/dL) with ASCVD — measured once in a lifetime (2026 ACC/AHA Dyslipidemia Class I, PMID 41824590)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildstatin_associated_muscle_symptoms
    Muscle pain / weakness on statin (CK <10x ULN) — verify with re-challenge (ACC/AHA 2018)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

TREATMENTrequiredDrives dose adjustment
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Recommended regimen

2026 ACC/AHA Dyslipidemia — risk-tier stepwise to LDL goal (absorbs 2022 ACC ECDP non-statin sequence)
axis: lipid_intensity_stepwisestep 1 - Step 1 — High-intensity statin (very-high / high / borderline-intermediate after CAC) per 2026 ACC/AHA Dyslipidemia
Selected step "Step 1 — High-intensity statin (very-high / high / borderline-intermediate after CAC) per 2026 ACC/AHA Dyslipidemia" — ASCVD secondary prevention OR LDL ≥190 OR DM 40–75 + risk factors OR PREVENT high-risk per 2026 ACC/AHA Dyslipidemia (PMID 41824590)
  • atorvastatin
    first line
    high_intensity_statin
    40–80 mg • PO • once daily
    triggers: secondary_prevention, LDL_>=190, high_PREVENT
    High-intensity LDL −49 to −55%; LDL nadir 2–4 wk, full effect ~4–6 wk. CTT per-1 mmol/L MACE RR 0.78 (0.76–0.80, PMID 21067804); 4S all-cause death RR 0.70 (0.58–0.85, PMID 7968073); 2026 ACC/AHA Class I
    rxcui 83367
  • rosuvastatin
    first line
    high_intensity_statin
    20–40 mg • PO • once daily
    triggers: secondary_prevention, high_PREVENT
    High-intensity LDL −52 to −63%; nadir 2–4 wk. JUPITER primary-prevention HR 0.56 (0.46–0.69, PMID 18997196); HPS risk-driven 24% RRR (19–28, PMID 12114036)
    rxcui 301542

outpatient playbook — drug actions (6)

  1. 1. high-intensity statin
    rxcui 83367
    Atorvastatin 40–80 mg OR rosuvastatin 20–40 mg • PO • once daily
    trigger: ASCVD / LDL ≥190 / DM with risk factors / PREVENT high-risk
    ACC/AHA 2018 Class I; CTT Baigent 2010
  2. 2. ezetimibe add-on
    rxcui 341248
    10 mg • PO • once daily
    trigger: LDL above risk-tier goal at 4–12 weeks
    IMPROVE-IT MACE HR 0.936 (0.89–0.99, PMID 26039521)
  3. 3. PCSK9 inhibitor
    rxcui 1665684
    Evolocumab 140 mg q2w / 420 mg monthly OR alirocumab 75–150 mg q2w • SC • q2w / monthly
    trigger: LDL above goal on statin + ezetimibe
    FOURIER HR 0.85 (0.79–0.92, PMID 28304224) / ODYSSEY HR 0.85 (0.78–0.93, PMID 30403574)
  4. 4. inclisiran (adherence-friendly alternative)
    rxcui 2588243
    284 mg at 0, 3 mo, then q6 mo • SC • q6 months
    trigger: PCSK9 candidate with adherence concern
    ORION-10/11 LDL −52.3% (48.8–55.7, PMID 32187462)
  5. 5. bempedoic acid (statin-intolerant)
    rxcui 2282403
    180 mg • PO • once daily
    trigger: Rechallenge-verified statin intolerance + cardiovascular risk
    CLEAR Outcomes MACE HR 0.87 (0.79–0.96, PMID 36876740)
  6. 6. icosapent ethyl for residual TG-related risk
    rxcui 1304974
    2 g BID with meals • PO • BID
    trigger: TG 135–499 + ASCVD/DM on statin
    REDUCE-IT MACE HR 0.75 (0.68–0.83, PMID 30415628) — caution AF/bleeding

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: LDL-C above target for risk class ACC/AHA 2018 Grundy; Lp(a) ≥50 mg/dL (≥125 nmol/L) — universal screen ACC/AHA 2018; Established ASCVD — secondary prevention ACC/AHA 2018.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Dyslipidemia / lipid management** (cardio.lipid.core.v1).
Scope: Confirm chronic management; very-high-risk secondary prevention triggers <55 mg/dL target ESC/EAS 2019

No severity triggers fired against current inputs.

Plan

Regimen axis: **2026 ACC/AHA Dyslipidemia — risk-tier stepwise to LDL goal (absorbs 2022 ACC ECDP non-statin sequence)** — step "Step 1 — High-intensity statin (very-high / high / borderline-intermediate after CAC) per 2026 ACC/AHA Dyslipidemia".
1. atorvastatin 40–80 mg PO once daily (high_intensity_statin, first line) — High-intensity LDL −49 to −55%; LDL nadir 2–4 wk, full effect ~4–6 wk. CTT per-1 mmol/L MACE RR 0.78 (0.76–0.80, PMID 21067804); 4S all-cause death RR 0.70 (0.58–0.85, PMID 7968073); 2026 ACC/AHA Class I
2. rosuvastatin 20–40 mg PO once daily (high_intensity_statin, first line) — High-intensity LDL −52 to −63%; nadir 2–4 wk. JUPITER primary-prevention HR 0.56 (0.46–0.69, PMID 18997196); HPS risk-driven 24% RRR (19–28, PMID 12114036)

Setting playbook (outpatient) — Risk-stratify with PREVENT (primary) or very-high-risk (secondary), achieve LDL goal stepwise, and integrate ASCVD prevention bundle ACC/AHA 2018 Grundy
3. high-intensity statin Atorvastatin 40–80 mg OR rosuvastatin 20–40 mg PO once daily — ASCVD / LDL ≥190 / DM with risk factors / PREVENT high-risk (ACC/AHA 2018 Class I; CTT Baigent 2010)
4. ezetimibe add-on 10 mg PO once daily — LDL above risk-tier goal at 4–12 weeks (IMPROVE-IT MACE HR 0.936 (0.89–0.99, PMID 26039521))
5. PCSK9 inhibitor Evolocumab 140 mg q2w / 420 mg monthly OR alirocumab 75–150 mg q2w SC q2w / monthly — LDL above goal on statin + ezetimibe (FOURIER HR 0.85 (0.79–0.92, PMID 28304224) / ODYSSEY HR 0.85 (0.78–0.93, PMID 30403574))
6. inclisiran (adherence-friendly alternative) 284 mg at 0, 3 mo, then q6 mo SC q6 months — PCSK9 candidate with adherence concern (ORION-10/11 LDL −52.3% (48.8–55.7, PMID 32187462))
7. bempedoic acid (statin-intolerant) 180 mg PO once daily — Rechallenge-verified statin intolerance + cardiovascular risk (CLEAR Outcomes MACE HR 0.87 (0.79–0.96, PMID 36876740))
8. icosapent ethyl for residual TG-related risk 2 g BID with meals PO BID — TG 135–499 + ASCVD/DM on statin (REDUCE-IT MACE HR 0.75 (0.68–0.83, PMID 30415628) — caution AF/bleeding)

Non-pharmacologic actions:
- Mediterranean / DASH diet ACC/AHA 2018
- Aerobic 150 min/week + resistance 2x/week ACC/AHA 2018
- Weight loss to BMI <25 ACC/AHA 2018
- Smoking cessation pharmacotherapy + counselling ACC/AHA 2018
- Cascade FH screening of first-degree relatives ACC/AHA 2018
- Vaccination bundle — flu, pneumococcal, COVID, RSV (AHA 2018)

AVOID / contraindication checks:
-  simvastatin amlodipine dose cap 20 mg (2026 ACC/AHA Dyslipidemia)
-  simvastatin macrolide / strong CYP3A4 avoid (2026 ACC/AHA Dyslipidemia)
-  gemfibrozil + statin avoid — myopathy/rhabdo (2026 ACC/AHA Dyslipidemia)
-  statin pregnancy/lactation avoid (2026 ACC/AHA Dyslipidemia)
-  icosapent ethyl AF + bleeding risk (REDUCE IT PMID 30415628)
-  bempedoic acid uric acid / tendon rupture risk (CLEAR PMID 36876740)

Monitoring

Regimen monitoring:
- Lipid panel 4–12 weeks after any change → q3–12 months at goal (2026 ACC/AHA)
- CK/LFT baseline; repeat only if symptomatic — interpret muscle Sx against nocebo (SAMSON PMID 34531021)
- A1c q3–6 months for statin-associated new-onset DM surveillance (2026 ACC/AHA)
- Transaminases q3 months first year of bempedoic acid (CLEAR PMID 36876740)
- Uric acid with bempedoic acid (CLEAR PMID 36876740)

Setting (outpatient) monitoring:
- Lipid panel 4–12 weeks after change → q3–12 months at goal ACC/AHA 2018
- A1c q6 months on statin if borderline DM JUPITER Ridker 2008
- LFT/CK only if symptomatic ACC/AHA 2018
- Annual ApoB / non-HDL trajectory ESC/EAS 2019

Follow-up plan: Cascade screen for FH; vaccinations; ASCVD bundle (BP, A1c, antithrombotic per CCD/STEMI engines) ACC/AHA 2018
- Close-out criterion: long-term + family-screen plan documented

Monitoring phase: 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

Disposition

Current setting: outpatient — Risk-stratify with PREVENT (primary) or very-high-risk (secondary), achieve LDL goal stepwise, and integrate ASCVD prevention bundle ACC/AHA 2018 Grundy

Disposition criteria:
- At goal → q6–12 month visits ACC/AHA 2018
- Not at goal → q1–3 month titration ACC/AHA 2018
- Refractory → lipid clinic referral ACC/AHA 2018

Escalation triggers (move to higher acuity):
- New ASCVD event → re-stratify as very-high-risk → LDL <55 target ESC/EAS 2019
- Statin intolerance verified by re-challenge → switch class or bempedoic acid CLEAR Nissen 2023
- Severe TG (≥1000) → fibrate + diet + alcohol abstinence + APOC3-targeted therapy referral ESC/EAS 2019

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] CK >10x ULN with muscle symptoms +/- renal injury (ACC/AHA 2018)
- [SEVERE] TG ≥1000 mg/dL — chylomicronemia syndrome / pancreatitis risk (ESC/EAS 2019)
- [SEVERE] LDL ≥190 untreated OR clinical FH (DLCN ≥6) OR genetic LDLR/APOB/PCSK9 variant (ACC/AHA 2018)

Citations

- 2026 ACC/AHA/AACVPR/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Dyslipidemia Guideline (PMID 41824590 JACC / 41824552 Circulation; retires 2018 blood-cholesterol guideline, absorbs 2022 ACC ECDP non-statin pathway) + ESC/EAS 2019 + ADA SoC 2026 [PMID:41824590](https://pubmed.ncbi.nlm.nih.gov/41824590/)
- Cited evidence (PMID 41824552) [PMID:41824552](https://pubmed.ncbi.nlm.nih.gov/41824552/)
- Cited evidence (PMID 21067804) [PMID:21067804](https://pubmed.ncbi.nlm.nih.gov/21067804/)
- Cited evidence (PMID 7968073) [PMID:7968073](https://pubmed.ncbi.nlm.nih.gov/7968073/)
- Cited evidence (PMID 12114036) [PMID:12114036](https://pubmed.ncbi.nlm.nih.gov/12114036/)

Last reconciled with current guidelines: 2026-05-26.
References
  • 2026 ACC/AHA/AACVPR/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Dyslipidemia Guideline (PMID 41824590 JACC / 41824552 Circulation; retires 2018 blood-cholesterol guideline, absorbs 2022 ACC ECDP non-statin pathway) + ESC/EAS 2019 + ADA SoC 2026 — PMID:41824590
  • Cited evidence (PMID 41824552) — PMID:41824552
  • Cited evidence (PMID 21067804) — PMID:21067804
  • Cited evidence (PMID 7968073) — PMID:7968073
  • Cited evidence (PMID 12114036) — PMID:12114036