Martin Equation for Low-Density Lipoprotein Cholesterol (LDL-C)

• Use the estimated LDL-C in conjunction with the patient's overall cardiovascular risk profile to guide lipid-lowering therapy decisions; examples of atherosclerotic cardiovascular disease (ASCVD) risk assessment tools include:
  
  • PREVENT.
  • 2013 AHA/ACC Risk Calculator.
  • SCORE2.
• Additional tests to consider:
  
  • In adults on lipid-lowering therapy who have achieved LDL-C and non-HDL-C goals, apolipoprotein B (apoB) may be reasonable to guide further management decisions, particularly those with: 
    
    • ASCVD.
    • Cardiovascular-kidney-metabolic (CKM) syndrome.
    • Type 2 diabetes.
    • Elevated triglycerides.
  • In all adults, measurement of lipoprotein(a) [Lp(a)] concentration is recommended at least once for ASCVD risk assessment.
• Monitoring and management guidance:
  
  • Repeat lipid profile and LDL-C calculation:
    
    • 4 to 12 weeks after initiation or intensification of lipid-lowering therapy.
    • Every 6 to 12 months thereafter.
  • All patients should receive health behavior counseling.

PRIMARY PREVENTION

The 2026 ACC/AHA Guideline provides the following guidance based on 10-year ASCVD risk categories (for adults aged 30–79 years with LDL-C 70–189 mg/dL):

• Low (<3% risk): Consider moderate-intensity statin therapy if:
  
  • LDL-C 160–189 mg/dL.
  • 30-year ASCVD risk is ≥10%.
• Borderline (3% to <5% risk): 
  
  • Moderate-intensity statin therapy, based on risk-enhancing factors and a clinician-patient risk-benefit discussion.
  • If shared decision-making does not produce a clear treatment path, consider coronary artery calcium (CAC) assessment.
  • Target a ≥30% LDL-C reduction with a goal of LDL-C <100 mg/dL and non-HDL-C <130 mg/dL.
• Intermediate (5% to <10% risk): 
  
  • Moderate- to high-intensity statin therapy.
  • Target a ≥30% LDL-C reduction with a goal of LDL-C <100 mg/dL and non-HDL-C <130 mg/dL.
  • If uncertainty remains regarding whether to initiate therapy or its appropriate intensity, consider CAC assessment.
• High (≥10% risk): 
  
  • High-intensity statin therapy, with additional therapies (e.g., ezetimibe, PCSK9 monoclonal antibodies [mAbs], bempedoic acid) as needed to meet goals.
  • Target a ≥50% LDL-C reduction with a goal of LDL-C <70 mg/dL and non-HDL-C <100 mg/dL.

The following groups should receive lipid-lowering therapy regardless of calculated risk:

• Established clinical ASCVD.
• LDL-C ≥190 mg/dL.
• Aged 40–75 with diabetes, chronic kidney disease stage 3 or higher, or HIV on stable combination antiretroviral therapy.

SECONDARY PREVENTION

• Start or continue high-intensity statin therapy, aiming for a ≥50% reduction in LDL-C.
• Not very high risk: 
  
  • Goal LDL-C <70 mg/dL and non-HDL-C <100 mg/dL.
  • Add ezetimibe, a PCSK9 mAb, or bempedoic acid if goals are not met on maximally tolerated statin therapy.
• Very high risk (≥2 ASCVD events, or 1 ASCVD event plus ≥2 high-risk conditions): 
  
  • Goal LDL-C <55 mg/dL and non-HDL-C <85 mg/dL.
  • Add ezetimibe and/or a PCSK9 mAb and/or bempedoic acid if goals are not met on maximally tolerated statin therapy.
  • Inclisiran may be considered for patients who prefer less frequent dosing or cannot use PCSK9 mAbs.

Please refer to your local guidelines for more detailed guidance (e.g., 2026 ACC/AHA Guideline, 2025 Focused Update of the 2019 ESC/EAS Guidelines).