When to intubate in GCS?

GCS ≤ 8 requires intubation for airway protection. The patient cannot protect their own airway at this level of consciousness. Motor score is the most prognostically important component.

What is the best initial fluid for sepsis resuscitation?

Lactated Ringer's (LR) is the preferred resuscitation fluid. The SMART trial (2018) showed balanced crystalloids reduced death, new renal failure, and persistent renal dysfunction compared to normal saline.

When to start vasopressors in septic shock?

Start norepinephrine (first-line vasopressor) if MAP remains < 65 mmHg after initial 30 mL/kg crystalloid resuscitation, or earlier if patient is profoundly hypotensive. Do not delay pressors to complete full fluid resuscitation.

Why can serum uric acid be normal during acute gout?

During acute inflammation, IL-6 increases renal urate excretion and redistributes urate from plasma to tissues. Up to 40% of acute gout flares have normal serum uric acid. Joint aspiration with polarized microscopy is needed for definitive diagnosis.

How do you distinguish lupus flare from infection in SLE?

Key clues: CRP is low/normal in flare but elevated in infection. Complement (C3/C4) drops in flare but is normal/elevated in infection. Procalcitonin is elevated in bacterial infection but normal in flare. Anti-dsDNA rises in flare, stable in infection.

What is the difference between DKA and HHS?

DKA features acidosis (pH 600), hyperosmolality (> 320), and minimal ketosis -typically in Type 2 DM. DKA requires insulin drip; HHS requires aggressive fluid resuscitation first.

When to give tPA in acute ischemic stroke?

IV alteplase (tPA) can be given within 4.5 hours of last known well time in eligible patients. CT head must rule out hemorrhage first. For large vessel occlusion, mechanical thrombectomy can be performed up to 24 hours with favorable imaging.

What antibiotics for community-acquired pneumonia?

Inpatient non-ICU: ceftriaxone + azithromycin. ICU: ceftriaxone + azithromycin (add vancomycin if MRSA risk). Outpatient healthy: amoxicillin. Outpatient with comorbidities: augmentin + azithromycin or respiratory fluoroquinolone. Duration: 5 days if clinically stable for 48 hours.

How to interpret iron studies?

Iron deficiency: low ferritin (< 30), high TIBC, low iron, low transferrin saturation (< 20%). Anemia of chronic disease: normal/high ferritin (acute phase reactant), low TIBC, low iron. A ferritin of 50-100 in an inflamed patient may still represent iron deficiency.

What is the correction rate for hyponatremia?

Correct sodium no more than 8 mEq/L in 24 hours to avoid osmotic demyelination syndrome (ODS). For symptomatic severe hyponatremia with seizures, give 3% hypertonic saline 100-150 mL bolus over 10-20 minutes. If overcorrected, use D5W + DDAVP rescue protocol.

When to start antibiotics in meningitis?

Within 30-60 minutes. Do NOT delay antibiotics for LP or CT. Draw blood cultures, start empiric antibiotics (vancomycin + ceftriaxone ± ampicillin if > 50 or immunocompromised), then perform LP when possible. Dexamethasone should be given before or with the first antibiotic dose.

DOACs vs warfarin in antiphospholipid syndrome?

DOACs are contraindicated in APS. The TRAPS trial (2018) showed rivaroxaban was inferior to warfarin with more thrombotic events in triple-positive APS patients. Warfarin with INR target 2-3 is the standard for APS, indefinitely.

How to manage scleroderma renal crisis?

ACE inhibitors (captopril) are life-saving -start immediately and titrate aggressively. Do NOT hold for rising creatinine. Steroids > 15 mg prednisone per day precipitate scleroderma renal crisis. ARBs are NOT a substitute -evidence is only for ACEi.

What are the 4 pillars of heart failure treatment?

Guideline-directed medical therapy (GDMT) for HFrEF: (1) ARNI or ACEi/ARB, (2) beta-blocker (carvedilol, metoprolol succinate, or bisoprolol), (3) MRA (spironolactone or eplerenone), (4) SGLT2 inhibitor (dapagliflozin or empagliflozin). All four should be initiated and titrated to target doses.

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CardiologyAmbulatory2026 Update

2026 ACC/AHA/Multisociety Dyslipidemia Guideline

First major update since 2018. Released March 13, 2026 by ACC/AHA with AACVPR/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA. Retitled from "Blood Cholesterol" to "Dyslipidemia" to reflect the broader scope (LDL + non-HDL + apoB + Lp(a) + remnants). Core principle: "lower LDL for longer is better" -cumulative exposure analogous to pack-years. Here is everything that changed from the 2018 guideline and why it matters for your practice.

⚖️ 2018 Cholesterol Guideline vs 2026 Dyslipidemia Guideline

Full Comparison Table

Domain	2018 ACC/AHA Cholesterol Guideline	2026 ACC/AHA/Multisociety Dyslipidemia Guideline	Impact
Risk Calculator	2013 Pooled Cohort Equation (PCE). Validated age 40-79, race input (Black / non-Black), 10-yr risk only.	PREVENT-ASCVD (Khan et al, Circulation 2024) replaces PCE. Validated age 30-79, race removed, adds eGFR / UACR (CKD), HbA1c, BMI, social deprivation index. Estimates 10-year AND 30-year ASCVD risk. Generally produces lower 10-yr estimates than PCE, especially in Black patients and the elderly.	Major
Risk Categories	Low < 5%, borderline 5-7.5%, intermediate 7.5-20%, high ≥ 20% (10-yr ASCVD).	New thresholds: low < 3%, borderline 3-< 5%, intermediate 5-< 10%, high ≥ 10%. Bands lowered to compensate for PREVENT producing lower scores than PCE -population qualifying for statin is roughly preserved, but the math is more equitable (no race input).	Major
Primary Prevention LDL Goal	No numeric LDL goal. Recommended "≥ 50% LDL reduction" with high-intensity statin in high-risk; "30-49%" with moderate-intensity in intermediate. No mg/dL target.	NEW: numeric primary-prevention LDL goals. PREVENT ≥ 10% → LDL < 55 mg/dL. PREVENT 5-< 10% → LDL < 70 mg/dL. Brings primary prevention closer to the secondary-prevention framework.	Major
Secondary Prevention LDL Goal (clinical ASCVD)	LDL < 70 mg/dL universally for clinical ASCVD. "Very-high-risk" (2018 / 2022 consensus) suggested < 55 but was less formally codified.	Split into two tiers, codified. Very-high-risk ASCVD → LDL < 55 mg/dL (apoB < 55). Standard-risk ASCVD (clinical ASCVD without VHR features) → LDL < 70. Lp(a) ≥ 50 mg/dL plus ASCVD newly added to the very-high-risk definition.	Major
Lp(a) Testing	"May be considered" as a risk enhancer in selected patients (FH, premature ASCVD family hx). Not routine.	Recommend Lp(a) measurement once per lifetime in all adults. Lp(a) ≥ 50 mg/dL (≥ 125 nmol/L) is a major risk enhancer. Lp(a) ≥ 50 + established ASCVD = "very-high-risk" → LDL goal < 55. Cascade-screen family. PCSK9i / inclisiran lower Lp(a) modestly (~15-25%); investigational siRNA/ASO agents are in trials.	Major
ApoB Testing	Listed as an optional risk enhancer; no quantitative target.	Routine measurement in patients with elevated TG (> 200), diabetes, low LDL on therapy, or borderline-risk decisions. Quantitative targets align with the LDL goal: apoB < 55 (when LDL goal is < 55, i.e., very-high-risk ASCVD or primary-prevention high-risk), < 70 (when LDL goal is < 70, i.e., standard ASCVD or primary-prevention intermediate), < 90 (lower-risk / borderline categories). ApoB > the matched LDL target even when LDL appears at goal → intensify therapy (small-dense-LDL / remnant pattern).	Major
Early Intervention (young patients)	No formal "early intervention" category. Young patients with LDL 160-189 and no other risk factors mostly received lifestyle counseling unless severe (LDL ≥ 190 / FH).	NEW dedicated category. Start statin earlier when any of: HeFH at diagnosis (including children age 8-10), age ≤ 30 with LDL ≥ 160, strong family hx of premature ASCVD, or high 30-year PREVENT risk. Rationale: cumulative LDL exposure ("LDL pack-years") drives lifetime ASCVD risk; delaying treatment in young high-LDL patients wastes the longest-yield treatment window.	Major
Diabetes Statin Indication	DM age 40-75 with LDL 70-189 → moderate-intensity statin. High-intensity if ASCVD risk ≥ 7.5% or risk enhancers.	Expanded to age 30-39 when LDL ≥ 160 or elevated 30-year PREVENT risk. Intensification driven by 10-year PREVENT ≥ 10%, established ASCVD, or multiple risk enhancers. ADA-aligned LDL goal < 70 if ASCVD; < 100 otherwise.	Moderate
Heterozygous FH (HeFH)	High-intensity statin recommended; treatment age generally adult.	Treat at diagnosis regardless of age. Supports statin in HeFH children from age 8-10. Combination therapy (statin + ezetimibe → PCSK9i / inclisiran) initiated earlier to reach goal. Cascade screening of first-degree relatives reinforced.	Moderate
Non-Statin Add-On Strategy	Stepwise ladder: statin → ezetimibe → PCSK9i mAb. Inclisiran not yet approved at time of 2018 publication; bempedoic acid had limited outcomes data.	Reframed as parallel options. After max-tolerated statin: ezetimibe / bempedoic acid / PCSK9i mAb (alirocumab, evolocumab) / inclisiran. Choose by cost, route preference, comorbidities, adherence. Combination therapy is the rule, not the exception, for very-high-risk ASCVD -starting two or three agents simultaneously is now explicitly supported when far from goal.	Major
Bempedoic Acid	Limited mention; outcome data not yet available.	Formally included as a non-statin option, especially for statin-intolerant patients. Supported by CLEAR Outcomes, 2023 -13% MACE reduction in statin-intolerant patients. PO daily; muscle symptoms minimal; small ↑ in uric acid / gout risk.	New
Inclisiran (siRNA)	Not approved; not in 2018 guideline.	Now formally included. Small-interfering RNA targeting hepatic PCSK9 mRNA. SC every 6 months after loading dose. ~50% LDL reduction; major adherence advantage. ORION-10/11, 2020. CV outcomes trial (ORION-4) ongoing.	New
HIV Primary Prevention	Treat per general primary-prevention guidance (PCE-driven); no HIV-specific recommendation.	Pitavastatin 4 mg recommended for primary prevention in HIV adults age 40-75 regardless of standard LDL threshold. Driven by REPRIEVE, 2023 -35% MACE reduction over 5 yr in low-to-moderate-risk HIV patients with LDL below traditional treatment threshold. Avoid simvastatin / lovastatin with protease inhibitors (CYP3A4).	New
Hypertriglyceridemia (ASCVD)	Statin first; fish oil / fibrate roles modest. REDUCE-IT not yet published.	Icosapent ethyl 2 g BID recommended for patients with established ASCVD (or DM with risk factors) and persistent TG 150-499 on statin. REDUCE-IT, 2019: 25% MACE reduction. Fibrate-class CV benefit beyond statin disproven by PROMINENT, 2022; fenofibrate retained only for pancreatitis prevention at TG ≥ 500.	Moderate
Lifetime Exposure Framing	Risk-based framework with discrete decisions at index visit.	"Lower LDL for longer is better" codified as a guiding principle. Cumulative LDL exposure ("LDL pack-years") drives lifetime ASCVD risk; CTT meta-analysis: each ~39 mg/dL LDL drop ≈ 22% MACE reduction per year, compounding over time. Drives earlier starts and lower targets.	Moderate
Statin Intensity Definitions	High (≥ 50% LDL ↓), moderate (30-49%), low (< 30%) with specific drug-dose mapping.	Unchanged from 2018 -atorva 40-80 / rosuva 20-40 = high-intensity; atorva 10-20 / rosuva 5-10 = moderate. No new drug-dose tiers introduced.	Maintained
CAC Scoring	Tiebreaker for borderline 5-7.5% PCE; "powerdown" strategy (CAC = 0 → defer statin) supported in selected patients.	Tiebreaker for borderline 3-< 5% PREVENT (band shifted). Same role -confirms or downgrades risk in patients near the SDM threshold. CAC = 0 still supports deferring statin in select primary-prevention adults > 55 years without DM, FH, or smoking.	Moderate
Lipid Screening Age	Adults starting at age 20; repeat every 4-6 yr if normal.	Maintained. Adults starting at age 20; repeat every 4-6 yr if normal. New 2026 layer: measure Lp(a) once per lifetime, apoB in selected patients (see above).	Maintained
Fasting vs Non-Fasting	Non-fasting acceptable; fasting if TG > 400 needed for Friedewald.	Maintained. Non-fasting acceptable; redraw fasting if TG > 400. Friedewald LDL inaccurate at TG > 400 or LDL < 70 -use direct LDL or Martin-Hopkins method in those settings.	Maintained

🔥 Key Changes at a Glance

Bottom Line: The 2026 ACC/AHA/Multisociety Dyslipidemia Guideline shifts lipid management toward earlier, lower, longer. PREVENT-ASCVD replaces the 2013 PCE (no race input, ages 30-79, 10- and 30-year risk). Primary prevention gets numeric LDL goals for the first time (< 55 high-risk, < 70 intermediate). Secondary prevention is split into very-high-risk (< 55) vs standard-risk (< 70). Lp(a) is measured once per lifetime in all adults, apoB routinely in residual-risk patients. Non-statin therapies are parallel options rather than a strict ladder. A new early-intervention category formalizes statin starts in young high-LDL patients (HeFH, age ≤ 30 with LDL ≥ 160, strong family hx).

🚨 The 7 Biggest Changes

1. PREVENT replaces the Pooled Cohort Equation

PREVENT-ASCVD is now the recommended risk tool for primary prevention age 30-79. Removes race as input, adds CKD (eGFR / UACR), HbA1c, BMI, social deprivation. Estimates 10- and 30-year risk. Generally produces lower 10-yr scores than PCE -especially in Black patients and the elderly.

2. New Risk Bands

Low < 3% / borderline 3-< 5% / intermediate 5-< 10% / high ≥ 10%. Replaces the 2018 PCE bands (< 5 / 5-7.5 / 7.5-20 / ≥ 20%). Lowered to compensate for PREVENT producing lower scores -population qualifying for statin is roughly preserved.

3. Numeric LDL Goals in Primary Prevention

NEW: PREVENT ≥ 10% → LDL < 55. PREVENT 5-< 10% → LDL < 70. 2018 had no numeric primary-prevention goal -only "≥ 50% reduction." Brings primary prevention closer to secondary-prevention math.

4. Two LDL Targets in Secondary Prevention

Very-high-risk ASCVD → LDL < 55, apoB < 55. Standard-risk ASCVD → LDL < 70. Lp(a) ≥ 50 + ASCVD newly defined as very-high-risk. 2018 used < 70 universally; 2022 consensus first proposed < 55, codified in 2026.

5. Lp(a) and ApoB Become Routine

Lp(a) once per lifetime in all adults. ApoB routinely in patients with TG > 200, DM, low LDL on therapy, or borderline-risk decisions. ApoB targets align with the LDL goal: < 55 (LDL goal < 55), < 70 (LDL goal < 70), < 90 (lower-risk / borderline).

6. Early-Intervention Category

NEW: formalizes earlier statin starts in HeFH at diagnosis (incl. children 8-10), age ≤ 30 with LDL ≥ 160, strong family hx of premature ASCVD, or high 30-year PREVENT. Rationale: cumulative LDL exposure ("LDL pack-years") drives lifetime risk -don't waste the longest-yield treatment window.

7. Non-Statin Add-Ons as Parallel Options

Reframed from strict ladder to parallel options: ezetimibe / bempedoic acid (CLEAR Outcomes 2023) / PCSK9i mAb / inclisiran (siRNA, SC q6mo). Choose by cost, route, comorbidity, adherence. Combination therapy is the rule, not the exception, for very-high-risk ASCVD -start two or three agents simultaneously when far from goal.

📊 By the Numbers

Endorsing Societies

Years Since Last Update

< 55

LDL Goal (Very-High-Risk + High-Risk Primary Prev)

30-79

PREVENT Validated Age Range

Full Clinical Protocol: Outpatient Lipid Management Topic → | External: Full Guideline (Circulation) → | ACC Press Release →

🆕 Entirely New in 2026

What's Genuinely New (Not Just Refined)

Several elements of the 2026 guideline did not exist in any form in 2018. These are the highest-yield "this is new" topics for board review and clinic.

📐 PREVENT 30-Year Risk Estimation

PCE only estimated 10-year risk. PREVENT estimates BOTH 10- and 30-year ASCVD risk. The 30-year horizon enables the new "early intervention" category -treat young patients with high lifetime exposure even when their 10-year score is low.

🎯 Numeric Primary-Prevention LDL Goals

For the first time in an ACC/AHA cholesterol guideline, primary prevention has explicit mg/dL targets: < 55 (high-risk) and < 70 (intermediate-risk). 2018 only specified percentage reductions without numeric goals. Aligns primary prevention with the secondary-prevention framework.

🧬 Routine Lp(a) Measurement

Once per lifetime in all adults. Genetic, doesn't change with lifestyle or statin. Lp(a) ≥ 50 mg/dL (≥ 125 nmol/L) = major risk enhancer. Lp(a) ≥ 50 plus established ASCVD = "very-high-risk" → LDL goal < 55. Cascade-screen first-degree relatives. PCSK9i and inclisiran lower Lp(a) modestly (~15-25%); investigational siRNA / ASO agents (pelacarsen, olpasiran, lepodisiran) in late-phase trials.

🧪 Routine ApoB Measurement

ApoB counts every atherogenic particle (one apoB per LDL, VLDL, IDL, Lp(a)). When LDL appears at goal but apoB exceeds it, the patient has small-dense-LDL or remnant-rich profile -still residual ASCVD risk. Targets align with the LDL goal: < 55 / < 70 / < 90 (matching LDL < 55 / < 70 / lower-risk respectively). 2018 mentioned apoB only as an optional risk enhancer.

🌱 Early-Intervention Category

Statin start before the traditional age-40 cutoff for any of: HeFH at diagnosis (including children 8-10), age ≤ 30 with LDL ≥ 160, strong family hx of premature ASCVD, or high 30-year PREVENT. Rationale: cumulative LDL exposure ("LDL pack-years") drives lifetime ASCVD risk -delaying treatment in young high-LDL patients wastes the longest-yield treatment window.

💊 Inclisiran (siRNA)

Small-interfering RNA targeting hepatic PCSK9 mRNA. SC injection at day 0, 90, then every 6 months. ~50% LDL reduction, sustained. Twice-yearly dosing is a major adherence advantage vs PCSK9 mAbs (q2-4 wk). ORION-10/11, 2020; CV outcomes trial (ORION-4) ongoing. Not in the 2018 guideline at all.

💊 Bempedoic Acid (Outcomes Data)

ATP-citrate lyase inhibitor; activated only in liver, not muscle (no myalgia). PO daily. CLEAR Outcomes, 2023: 13% MACE reduction in statin-intolerant patients with or at high risk for ASCVD. Now formally included in the 2026 ladder. Watch for ↑ uric acid / gout.

🦠 HIV Primary Prevention (REPRIEVE)

Pitavastatin 4 mg recommended in HIV adults age 40-75 regardless of standard LDL threshold. REPRIEVE, 2023: 35% MACE reduction over 5 yr. Avoid simva / lova with protease inhibitors (CYP3A4); pitavastatin or pravastatin preferred.

🐟 Icosapent Ethyl for Residual TG-Driven Risk

Icosapent ethyl 2 g BID for ASCVD (or DM with risk factors) and persistent TG 150-499 on statin. REDUCE-IT, 2019. Distinct from generic OTC fish oil (mixed EPA / DHA), which has not shown CV benefit. PROMINENT, 2022 closed the door on fibrate-class CV benefit beyond statin -fenofibrate retained for pancreatitis prevention at TG ≥ 500.

📜 "Lower for Longer" Mantra

First time codified as a guiding principle in an ACC/AHA cholesterol document. Cumulative LDL exposure ("LDL pack-years") drives lifetime ASCVD risk; CTT meta-analysis shows each ~39 mg/dL LDL drop ≈ 22% MACE reduction per year, compounding over time. Drives earlier starts and lower targets.

Key Trials Supporting the 2026 Changes

Trial	Year	Finding	2026 Impact
FOURIER	2017	Evolocumab on top of statin: 15% MACE reduction; safe down to LDL ~ 30	Supports lower LDL targets and PCSK9i add-on
ODYSSEY OUTCOMES	2018	Alirocumab post-ACS: 15% MACE reduction; mortality benefit in LDL ≥ 100 subgroup	Supports PCSK9i in very-high-risk ASCVD
REDUCE-IT	2019	Icosapent ethyl 2 g BID on statin (TG 135-499): 25% MACE reduction	Codifies icosapent ethyl for residual TG-driven risk
ORION-10/11	2020	Inclisiran q6mo: ~50% LDL reduction sustained	Inclisiran formally entered the 2026 ladder
PROMINENT	2022	Pemafibrate: lowered TG ~26% but NO MACE reduction	Closed the door on fibrate-class ASCVD benefit; fenofibrate now only for pancreatitis prevention
CLEAR Outcomes	2023	Bempedoic acid in statin-intolerant: 13% MACE reduction	Bempedoic acid formally entered the 2026 ladder
REPRIEVE	2023	Pitavastatin 4 mg in HIV age 40-75 below standard LDL threshold: 35% MACE reduction	HIV-specific primary-prevention statin recommendation
PREVENT (Khan et al)	2024	New ASCVD risk equations: race-free, ages 30-79, adds CKD / HbA1c / SDI, 10-yr + 30-yr	Replaced the 2013 PCE as the recommended risk tool
CTT meta-analysis	2010 / 2015	Each ~39 mg/dL LDL drop ≈ 22% MACE reduction per year	Foundation for "lower for longer is better" principle

Full Clinical Protocol: Outpatient Lipid Management Topic → | External: Full Guideline (Circulation) → | ACC Press Release → | National Lipid Association Summary →

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