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So now to talk about ASCVD and really our clinical decision making. I have no disclosures. So, what we do with our patients is we break them down into groups, right? We look at what is their risk. And the recommendations are very clear. For those who are very high risk, those with clinical ASCVD, those with diabetes, those with an LDL at or greater than 190, they should be on lipid lowering therapy, right? This is what the recommendations all recommend. They, of course, we do need to talk with our patients. We need to counsel them, you know, no recommendations tell us not to do that, but they're all very clear that our patients should be on lipid-lowering therapy if they fall into these groups. Where things get more complicated are when we're using our risk calculator to determine low, intermediate, and high risk, right? So our patient with diabetes, we don't need to risk calculate. We know that they should be on lipid lowering therapy. But many people, they don't fall into a group where they immediately should be on lipid-lowering therapy, and that, that's a good thing, right? We're, we're happy that our patients overall are healthy, right? So that's, that's good. For our patients, we're then going to need to risk calculate and we're going to also need to consider risk enhancing factors because these calculators, they don't consider everything and that's really where we need to sit with our patient and we need to discuss what may increase their risk. So most of us are using the 2013 PCE calculator, and this is what it looks at. It looks at cholesterol levels. It looks at whether the patient smokes, whether they're diabetic, whether they're hypertensive, and then it looks at their age, their sex, and their race. So there's a lot left out here that increases a patient's risk that it doesn't consider, right? It doesn't consider. You know, are they pre-diabetic, right? Do they have general, in a general inflammatory process? There are many things it doesn't look at. Now, many of us use this calculator because it's built into many EMRs, right? It's built into my EMR and it's very, very convenient when you're Doing that. I realized that we're all short on time and that anything that can help us is really, really good, but it's built into EMRs. It pulls the data out of the EMR and it just gives you the numbers. So it's really easy to sit there, look at the number when you're with the patient and see what is their risk. So, you know, we just need to consider, well, what other risk factors are present on that patient because we do need to recognize that this is leaving a lot out. So a clinical scenario. Mrs. Jackson, a 55 year old white female, presents for a follow-up visit during which she requested routine blood work. Her family history is unknown. By lifestyle, she's a quarter pack smoker a day. She's trying to stop. She has social alcohol use. She denies, defines it as about 1 to 2 drinks a week, no drug use. She lives alone in an apartment in a historically underserved area. As you talk with her, she says she doesn't go to a gym because she can't afford it, and that there's no nearby parks for her to walk to, and she doesn't really have any grocery stores that she can get to nearby. It's what is considered a grocery store desert. She works as a cashier. Her diet, without having access to a nearby grocery store, is pretty heavy in fast food. At the visit, her BP is 140/80. Her BMI is 33.2. Labs show an LDL of 142, an HDL of 35, an A1C of 6.2, and a GFR of 58. When we use the 2013 calculator, her CVD risk is 9.1%. So based on this, what is the most appropriate initial recommendation for this patient? Initiate a high intensity of statin immediately to reduce her LDL by at least 50%. B. Start a moderate intensity statin and set a goal to reduce her LDL by 30%. C. Focus solely on lifestyle changes and reassess her risk factors in one year. Begin a shared decision-making discussion to consider her risk factors and preferences for statin therapy. Or, her risk is too low to warrant any intervention at this time. So give everyone some time here. OK. Good. So the answer here is D. So she falls into that intermediate risk category, which means we're going to begin a shared decision-making discussion, looking into her risk factors and her preferences for statin therapy. So looking at the recommendations, those who fall into a low-risk category, less than 5%, focuses generally on lifestyle modification. So this is gonna be, let's look at your diet, you know, how much fiber do you eat? Do you eat a lot of processed carbs, a lot of processed fats? You know, do you get good exercise? Are we addressing things like smoking? You know, are we addressing stress, good sleep? There's a lot to lifestyle. So we really wanna sit with our patients and have the time to go over lifestyle with them. Where the group becomes problematic is the intermediate risk group, 7.5% to less than 20%. Because Patients often don't want to be on medication, but the question is, should they be on medication? Of course, it's easy for us just to put everyone on medication, but that doesn't mean it's the right decision. The official recommendations are to have a shared, a shared decision-making discussion with the patient, discussing their risk factors, discussing our goal to have their LDL below 100. And if we do start a statin, it should be moderate intensity to reduce the LDL by 30%. I find these visits can, can be, you know, time-consuming because you're sitting with the patient and you're really going over with them, you know, why you want to lower their cholesterol. You know, cholesterol can be very difficult for patients to comprehend. I can give them a BP cuff and they can see their BP, and patients associate high BP with problems. I can also give them a glucometer and they can check their blood sugar, and they associate a high blood sugar with problems and often they don't feel well. Often they'll say, you know, I'm thirsty a lot when my blood sugar is high. I, I feel really tired when it's high. Same with high BP, you know, they'll often report headaches. But high cholesterol is very different. Patients don't have that same wherewithal about, about it. They don't say, you know, I feel bad when my cholesterol is high, and it, of course, does take time for it to change. So, so it becomes a lot more difficult to have that discussion because patients don't understand it like they understand high BP and high blood sugar. High risk is, is a lot clearer. For patients whose risk is above 20%, it's recommended to start a high-intensity statin to reduce LDL by at least 50%. When we look at goals with diabetes, you wanna have it below 70, your LDL below 70. Goals are starting to shift. So for established ASCBD and a high risk of recurrence, goals are starting to suggest that we should actually aim for a very low LDL below 55. This coming out of the American Association of Clinical Endocrinologists and are starting to see people starting to do this. So just something to keep in mind. If you're unsure which, you know, which recommendation to turn to, I think it's safe to say that below 55 is, is, is fine to do based on the newest recommendations. Young adults, so when you check someone under the age of 40, which of course are not, not who the recommendations were made for, so those adults 20 to 39, you still wanna have a discussion with them about their lifestyle. Now, obviously, if they fall into a high-risk group, they have diabetes, their LDL is above 190, right? Then you're obviously going to start them on a statin because they should be on or, or lipid-lowering therapy, excuse me, because they should be on it. For those 20 to 39 who have elevated cholesterol, but otherwise, you know, they don't fall into one of those high-risk groups, you're going to talk to them and you're gonna again have a shared decision-making discussion about are there reasons they should be on a cholesterol-lowering medication because it is possible that they should be. So again, we're gonna have that shared making shared decision-making discussion with them. For those with familial hypercholesterolemia, we need to identify who they are because not everyone knows they have it. But if you take a thorough family history and you recognize numerous people who have had heart disease, particularly heart disease early in life, that really should raise the antenna that this exists in the family. People with familial hypercholesterolemia carry a two-fold increased risk of CAD even when we get their LDL down below 190. Recommendations are to screen children with a known family history of familial hypercholesterolemia. And if their LDL is above 160, we should consider starting them on lipid-lowering therapy. And of course, anyone with an LDL above 190 should be started on lipid-lowering therapy regardless of whether they have this running in their family or not. So our risk calculator that many of us are using our 2013 risk calculator. It can be, there's a lot of questions about it, and it's