Early Risk Detection and Early Treatment: 2026 Lp(a) & Cholesterol Guidelines

Join internist and cholesterol expert Albert Lopez, DO, FACP, FASPC, as he reviews the new 2026 Cholesterol Guidelines. In this segment, he focuses on new risk assessment guidelines, including the genetic risk factor Lipoprotein(a) and a sign of damage, the CAC score, and the recommendation that risk assessment starts much younger, around 30 years old. He discusses treatment options for high cholesterol, including sound evidence for statins and newer treatments for rare cholesterol manifestations.

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Transcript

Why Early Lipid Treatment Matters

Albert Lopez, DO 0:00

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, cardiovascular disease.

Meet Dr. Albert Lopez

Albert Lopez, DO 0:22

Hi, I'm Dr. Albert Lopez. I'm an internist. I'm a lipid specialist. My focus in my practice is general internal medicine, but I do a lot of cardiometabolic disease, diabetes, and cholesterol treatment.

What The 2026 Guidelines Change

Albert Lopez, DO 0:36

I'm going to be speaking today on the new 2026 cholesterol guidelines. So these 2026 guidelines are 12 medical societies, so a multi-specialty guideline that is new in almost a decade. We're back to looking at measurements early of several metrics on cholesterol, including LDL, non-HDL, APOB, which is another way to look at particles that can cause plaque in the arteries. And we're looking at triglycerides. These guidelines are asking us to look much earlier at lipids, at young children, two to four, if they have risk, family history and risk of cardiovascular disease or high cholesterol, young individuals starting at 19 years old and checking every five years, and then starting therapy really early so we can prevent cardiovascular disease, which is a lifelong progression of disease, and preventing that event from ever happening, like stroke or heart attack or valvular disease.

Targets For LDL And Better Markers

Speaker 1 1:42

Dr. Lopez, there were some differences in screening about biomarkers. Can you tell us about LDL?

Albert Lopez, DO 1:49

So in this current guideline, we have definitive goals to achieve, and LDL goals have lowered at this point. Because the newer studies show that the lower we have LDL the less progression there is of the disease and the better outcomes we have; hopefully never having an event. SO now, people at low risk, the LDL goals are to be 100. People with moderate risk, the goal is to be under 70. People at high risk, so people with known heart disease or have had strokes, LDL should be below 55.

Lp(a) And Lifetime Genetic Risk

Speaker 1 2:32

Dr. Lopez, what is Lp(a)? Can you tell us a little bit about that?

Albert Lopez, DO 2:37

So Lp(a) is uh this is the first time it's been in the guidelines. Lp(a) is a cholesterol-like protein that is different than LDL cholesterol. It is genetically mediated, meaning that it runs in families. It is an independent risk marker from other risk factors like high blood pressure, high sugars, or high or other high cholesterol measurements. Lp(a) does augment your risk two to four fold for developing cardiovascular disease. Lp(a) should be measured in nanomoles per deciliter. There's two ways to measure it, but it seems this is more accurate and more accepted. And if your Lp(a) is above 125, that's significant. The higher it is, the more risk you have throughout your whole lifetime.

CAC Scans To Reveal Hidden Plaque

Albert Lopez, DO 3:31

CAC score or CAC, most commonly called CAC or coronary artery calcium score, is a measurement of plaque burden. So what I mean by that is when plaque or cholesterol deposits into your arterial wall, as we call plaque in the wall, it as it cools down, you leave a deposition of calcium there. This is done by a CAT scan of the chest. It is not a blood test. It's done by a score where they measure the amount of calcium. It's put through an algorithm and they measure this and rate it from zero to 400 or above. Zero, the risk is very low for disease. 100 means that you have mild disease. Over 300, you have significant disease. Over 400 is very significant disease, you probably have significant heart disease. And over a thousand is alarming. It's another way to look at risk factors, and it's another way to screen people to see if they have asymptomatic or coronary disease or cardiovascular disease without any symptoms. And hence then you can decide if we're going to start treatment at that point. Anybody with a CAC score over 100 should be started on some lipid lowering therapy, preferably statins at first.

Speaker 1 4:54

Dr. Lopez, what is new that's added on risk assessment?

Metabolic Risk And Insulin Resistance

Albert Lopez, DO 4:59

So this year we've talked about chronic kidney disease, but we've also talked about metabolically associated disease as well. And this includes diabetes and commonly called prediabetes or elevated blood sugars. This sets up an inflammatory cascade and it sets some of the cholesterol particles to change that become risk factors for developing plaque later on in life. This also is associated with increased weight gain and obesity. And I think this 2026 guideline touches on it. I wish it spent a little more time on insulin resistance or prediabetes and obesity, because I think this is our new epidemic in the world, not just in this country, in the United States. Worldwide, central obesity, subclinical fat, insulin resistance is really the big problem that's driving cardiovascular disease at this time. In insulin resistance, what I mean is that you're having an elevated sugar above 88 when you're fasting. So your sugar theoretically should never be above 88. That below 88 is normal 88 and below is normal. But above that, now you're starting to not utilize this sugar well, and this causes a cascade of problems: fatty liver, kidney disease, heart disease, diabetes eventually. So we have to reverse this.

Speaker 1 6:32

Dr. Lopez, when do we start the risk assessment on people?

Risk Scoring Starts At Age 30

Albert Lopez, DO 6:36

So in this guidelines, they've been using the prevent risk score or risk assessment. And we've gone through several through time. This seems to be one of the most encompassing risk assessments. And it should be started at 30 years old. Because again, remember cardiovascular disease is a lifetime risk. The longer you have risk, the more chance you're going to have it. The higher you have of risks, the higher the risks are, the more chance you're going to have cardiovascular disease. So we're starting at 30 now, much younger.

Speaker 1 7:08

And what are the treatment steps for someone with cardiovascular disease?

Lifestyle Steps That Move The Needle

Albert Lopez, DO 7:13

So in the treatment, we start with the basics of exercise and eating lifestyle, commonly called diet. So changing eating lifestyle to have lower fatty proteins, more lean proteins, fish, chicken, plant-based proteins. We can add the DASH diet, which is low sodium, high fiber. We can and more complex fibrous type foods, or the PREVED diet, the Mediterranean diet is also called PREVED diet. So eating lifestyle changing, getting oneself to ideal body weight is shown big a large benefit. And exercise. The guidelines have been very consistent for a long time. And this 2026 guidelines have has restated 120 minutes a week. That includes two times a week, something that's moderate to high intensity exercise for 20 to 30 minutes, and twice a week, resistance training. So using body weight or using weight. So that's what I mean by resistance training for upper body as well as lower body. And this is shown great benefit, not just in cardiovascular disease, but just in aging in general. Resistance training is and anaerobic exercise is very important. When we're talking about treatments by medications, there is other natural compounds that could be used, but the outcomes are not really as aggressive or not really shown to have great outcomes in reducing cardiovascular

Statins First And Safety Myths

Albert Lopez, DO 8:44

events. But by far, statin therapy has been shown by far the greatest reducer of cholesterol and reduction of risk. And this study discusses how safe we've shown it has been. In the past, we've heard that it will kill your liver. We've disproven that. In fact, people with known liver disease or have two to three times high risk of cardiovascular disease, they should be on a statin. And the dementia risk is not there. That's been disproven in 32 countries, 14 studies in over 7 million patients. So that's been disproven, the dementia theory. But statins first. And then if you're not getting to goal with that statin, then we should move to other lipid lowering therapies, including ezetimibe. If that doesn't work, then we can use to a PCSK9, which is currently injection every two weeks. But studies have shown we have two new drugs coming on them, possibly coming on the market that are oral in the PCSK9 realm in that category. And then we can use other drugs like inclisiran and other drugs from there, bempedoic acid, for example. And in fact, if there is muscle aches or we call statin myalgias, with myalgia is the medical term for muscle aches, we can move directly to either ezetimide or bempedoic acid at that point. And if we can add a very low dose of a statin, it would give added benefit if we can do both. So after ezetimide, which is cheap and it's easy to get and it has really very low risk profile side effects are very, very low with this drug. We can use a PCSK9 , which is an injection every two weeks. It works on a pathway that prevents cholesterol from increasing and reduces cholesterol. And as I mentioned, there's we're studying two drugs that look very promising that are PCSK9 that are oral, their

Next-Line Drugs And New Options

Albert Lopez, DO 10:45

tablets. Inclisiran also works on the PCSK9 pathway by a different mechanism. And this is also an injection. It's done every six months. It's almost like a cholesterol vaccine. So we're seeing great LDL reduction with inclisiran. We're waiting for the final outcome studies and seeing how much it reduces the rate of heart attack or stroke. And that's coming up soon. We have also drugs for kind of more rare diseases like very, very high triglycerides. Those are the class called Apo C3, you know. But we have drugs like icosapent alcohol, which is a super refined pharmaceutical grade, for lack of a better term, omega-3 fatty acid. I don't want to call it fish oil because it's not really a fish oil, but this has shown risk benefit as well in cardiovascular disease and stroke.

Key Takeaways And Where To Learn More

Albert Lopez, DO 11:36

So in summary, this 2026 guidelines focuses on identifying risk early, treating earlier, getting to a lower goal so we can prevent an event. For example, heart attack or stroke. So we know that earlier, longer, the better.

Speaker 1 11:57

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