In addition to traditional risk factors such as smoking, high blood pressure and high blood sugar, the new guideline adds factors like family history and ethnicity, as well as certain health conditions such as metabolic syndrome, chronic kidney disease, chronic inflammatory conditions, premature menopause and high lipid biomarkers, to better identify individual risk and treatment options. The most significant change from the previous guideline is the inclusion of lipoprotein (a) (Lp(a)).

Lp(a) is a modified form of low density lipoprotein (LDL) to which another glycoprotein, termed apolipoprotein (a), is covalently bound. Lp(a) contributes to atherogenic risk by several mechanisms that include inhibition of fibrinolysis, increased cholesterol deposition in the arterial wall, and enhanced oxidation of LDL cholesterol. A family history of premature Atherosclerotic Cardiovascular Disease (ASCVD) or a personal history of ASCVD, not explained by major risk factors, strongly suggest measuring Lp(a). This lipoprotein parameter increases ASCVD risk, particularly at higher levels. In the new guideline  an increase of Lp(a) above ≥50 mg/dL or ≥125 nmol/L  is considered to be a risk-enhancing factor. Evidence showed that Lp(a) should be considered in women only in the presence of hypercholesterolemia.

Reference:
Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol.