ASCVD Risk Stratification Series (Part 1/3): Before the Risk Calculator [Pre-2026 Guidelines]

Note: This episode reflects pre-2026 dyslipidemia guidelines. Some recommendations may no longer align with current guidelines. 

ASCVD risk stratification should be straightforward, but in real clinic time, it often isn’t. Multiple guidelines, limited time, overlapping categories, and nonstop competing priorities make lipid decisions feel harder than they need to be.

In Part 1 of this LipidCurious mini-series, I walk you through how I approach ASCVD risk BEFORE I ever open an ASCVD Risk calculator using a practical, repeatable framework grounded in the 2018 AHA/ACC guideline, with AACE, NLA, and ADA guidance layered in where it adds clarity.

In this episode, we cover:

1. Why ASCVD risk stratification matters
2. Where I start every single time (screening & what to check)
3. The THREE questions that guide most lipid decisions!

• Clinical ASCVD?
• LDL-C ≥190 mg/dL?
• Diabetes Mellitus age 40–75?

Bonus: You’ll also hear two quick cases that show how much you can decide without a calculator.

Join the Learn at Pinnacle app ⁠to earn FREE CE Credit for listening to this episode! 

Disclaimer: This podcast is intended for educational purposes for clinicians and healthcare professionals. It does not provide medical advice, establish a physician–patient relationship, or replace individualized clinical judgment. The opinions expressed are those of the creator and do not represent the views of any affiliated institutions or organizations. 

Transcript

ASCVD Risk Stratification Series (Part 1/3): Before the Risk Calculator [Pre-2026 Guidelines]

Note: This episode reflects pre-2026 dyslipidemia guidelines. Some recommendations may no longer align with current guidelines. 

Hi everyone.
Welcome back to LipidCurious—an educational platform focused on simplifying lipid management for clinicians.

I’m your host, Dr. Vishnu Priya Pulipati, a board-certified Endocrinologist and Lipidologist.

In the last episode, I introduced a LipidCurious project called How to Assess ASCVD Risk Stratification and Optimize Lipid Therapy. I originally planned this as a formal course.
But as I was building it, I realized this framework would be far more useful if it were widely accessible.

So instead of a formal course, I decided to release this as a focused three-episode podcast series.

My goal is simple: to give you a repeatable, evidence-based way of thinking about ASCVD risk and lipid decisions that actually works in real clinic time.

If you already have a system that works well for you, that’s great.

If you manage adult lipid disorders, review lipid panels every day, and sometimes unsure what to do next, you’re in the right place.

Today, I want to walk you through how I approach ASCVD risk before I ever open a risk calculator.

Let me start by addressing the elephant in the room.

ASCVD risk stratification often feels confusing. For a long time, it felt that way to me too. 

But here’s the key point: the confusion isn’t because the science is weak.

We actually have a lot of high-quality guidelines. The problem is that we have too much of it—multiple guidelines, overlapping categories, different terminology, and plenty of exceptions.

And on top of that, most of us aren’t just managing lipids.

We’re managing diabetes, blood pressure, thyroid disease, obesity—often in the same visit. Lipid decisions may get two to five minutes, at best.

So the overwhelm isn’t about knowledge alone.
 It’s about time—and the lack of a simple, usable framework.

Most clinicians aren’t asking, “What do the guidelines say?”
They already know.

They’re asking, “Which one do I use, and how do I apply it to the patient in front of me?”

That’s exactly the problem this framework is meant to solve.

For this series, I primarily use the 2018 ACC/AHA cholesterol guideline as my foundation. I find it well structured and practical for day-to-day decision-making.

Guidance from other societies—such as AACE, NLA, and ADA—is layered in where it adds clarity or fills the literature gaps.

The goal isn’t to compare guidelines.
 It’s to use them cohesively.

This is an LDL-C–driven prevention framework. We’re not diving into pediatric lipid disorders, triglyceride-driven pathways, or rare genetic syndromes here. Those topics matter—they’re just outside the scope of this series.

This is evidence-based, but not evidence-exhaustive.
The goal is usefulness in real-world clinical decision-making.

In this episode, we’ll focus on three things:

1. The purpose of ASCVD risk stratification
2. Where I start every single time
3. The three questions that guide everything

If you haven’t already, I recommend exploring the complimentary LipidCurious Starter Kit at lipidcurious.com—it reinforces many of the concepts we’ll discuss today.

Alright—let’s get into it.

The purpose of ASCVD risk stratification is to help us:

• Identify who benefits most from therapy
• Match treatment intensity to an individual patient’s risk
• Promote consistent and equitable care among clinicians

Risk stratification is not about labeling patients.
It’s about making better—and often lifesaving—treatment decisions.

Where I Start Every Single Time

If you know me , I always start with the basics. Lets start with who to screen, how often, and what to order. 

Who to screen

All adults age 20 and older should be screened at least once.
Routine screening is emphasized between ages 40 and 75, where evidence is strongest.

How often

Every five years for most adults.
Consider annual screening with:

• Family history of premature ASCVD
• Known ASCVD or major ASCVD risk factors
• Middle-aged adults with evolving risk

Screening frequency should reflect risk, not just age.

Family history deserves a brief pause. Premature ASCVD is defined as events before age 55 in men or 65 in women in first-degree relatives parents and siblings.

But real life isn’t always neat.
 If I hear about multiple early events clustered on one side of the family, I take that seriously.

Guidelines guide. They don’t replace judgment.

What I order:

I start with a non-fasting lipid panel for most patients.

I switch to fasting if triglycerides are over 400, I suspect a genetic disorder, the patient recently had a high-fat meal, or there’s a strong family history.

I usually start with just the basic panel.

To refine risk, I may add: non-HDL-C, ApoB and Lp(a)

The Three Questions That Guide Everything

Before I ever open a risk calculator, I ask myself three questions:

1. Is there clinical ASCVD?
2. Is the LDL-C persistently ≥190 mg/dL?
3. Is the patient 40–75 years old with diabetes?

Yes to any one of these—and I’m already thinking about treatment.

This is literally how my brain works in clinic.

Patient in front of me. Lipid panel open. Something looks abnormal.
 I pause and ask myself:

• Do they already have preexisting ASCVD? No! then
• Is the LDL more than 190 mg/dL for no reason? No! then
• Are they 40 to 75 years with diabetes?

Yes to any of those—I move toward treatment.

Question One: Clinical ASCVD

I simplify ASCVD by organ system: brain, heart, blood vessels.

• Ischemic stroke or TIA
• Myocardial infarction, stable or unstable angina, or prior revascularization
• Aortic Aneurysm, PVD (claudication with abnormal ABI, prior revascularization or amputation)

If a patient has any of these due to atherosclerosis, they have clinical ASCVD. 

My starting point is high-intensity statin therapy.

Moderate intensity may be reasonable in advanced age, intolerance, or ischemic HFrEF—but conceptually, I always start at high intensity.

Guidelines use different terms—very high risk, extreme risk—and that can feel confusing.

I always wondered what difference does it make I am starting with high intensity statin anyways right. This distinction isn’t about what you start—it’s about how aggressive you need to be after you start. 

Here’s how I simplify very high risk:

• MORE disease (more than 1 ASCVD event)
• RECENT disease (ACS or revascularization within 12 months) or
• SYSTEMIC burden
  • Advanced age: ≥65 years
  • Comorbidities: Heterozygous FH, CABG/PCI, DM, HTN, CKD, CHF
  • Persistent risk factors: Smoking, LDL ≥100 mg/dL

Question Two: LDL ≥190 mg/dL

If there’s no ASCVD, I ask:
 Is the LDL persistently over 190?

Before medication, I rule out secondary causes—diet, medications, hypothyroidism, liver or kidney disease.

Once confirmed, this is severe primary hypercholesterolemia with high lifetime ASCVD risk.

Just like ASCVD, the starting point is high-intensity statin therapy.

Question three: Diabetes age 40–75

Diabetes between 40 and 75 gets at least a moderate-intensity statin.

I escalate to high intensity with:

• Older age above 65
• Longer duration of diabetes: 10 years or more for type 2, or 20 years or more for type 1
• Diabetes-related complications: retinopathy, albuminuria, reduced eGFR below 60, neuropathy, or an ABI under 0.9
• Or a 10-year ASCVD risk ≥20%

Lets apply this to 2 quick hypothetical cases

Case one:
58-year-old man, recent MI with stents six months ago, CKD stage 3, LDL 124, not on lipid therapy.
Clinical ASCVD present → high-intensity statin, they had recent and systemic Dz à aggressive approach.

Case two:
62-year-old woman, type 2 diabetes for 3 years now with neuropathy and CKD stage 3a, LDL 120.
Moderate-intensity statin, they have Cx à high intensity statin.

You made those decisions without opening a calculator.

Take-Home Points

• ASCVD risk stratification matters. It helps you make meaningful, consistent, evidence-based decisions in real clinic time.
• Screen adults age 20 and older at least every five years, and annually when risk is higher. Begin with a non-fasting lipid panel. Use non-HDL cholesterol, ApoB, and lipoprotein(a) selectively to refine risk.
• Remember the three triggers for treatment. Clinical ASCVD, LDL-C ≥190 mg/dL, or diabetes between ages 40 and 75 → start thinking treatment.

Alright folks I will see you back in two weeks with part 2 of this series.

Before I sign off, a quick note. This podcast is intended for educational purposes for clinicians and healthcare professionals. It does not provide medical advice, establish a physician patient relationship, or replace individualized clinical judgment.

Thank you for tuning in to LipidCurious. If today’s episode was helpful, consider sharing it with a colleague. You can always reach me at hello@lipidcurious.com.

Be sure to follow or subscribe so you do not miss what is coming next.

Until next time,
Stay curious and stay confident.

Signing off,
Dr. Pulipati.