Staging the Heart: NLA and EAS Reveal a New Era of Precision Lipidology and Imaging

The landscape of cardiovascular prevention is shifting from a focus on surrogate biomarkers to a more granular, image-based assessment of actual disease burden. This was the central theme at the joint session of the National Lipid Association (NLA) and the European Atherosclerosis Society (EAS) during the 2026 NLA Scientific Sessions, happening June 11 through 14 in Chicago.¹ As clinical practice moves toward "staging" coronary disease similar to how oncology stages cancer, the role of the pharmacist as a gatekeeper of therapy and an educator on residual risk has never been more critical.

A Global Shift in Statin Guidelines

EAS President Børge Nordestgaard, MD, DMSc, opened the session by detailing the 2025 focused update to the ESC/EAS dyslipidemia guidelines. For the first time, clinicians have explicit guidance on statin use in cardiovascular-healthy individuals based on refined risk-scoring systems: SCORE2 for patients under 70 and the new SCORE-OP for those aged 70 to 90.²

The update recalibrates statin thresholds based on a country's baseline cardiovascular risk. In "very high risk" regions, statins should be considered for women as young as 45 and men as young as 40. For "low risk" countries such as Denmark, the threshold shifts to women over 70 and men over 60. Nordestgaard emphasized that reaching age 70 is no longer a reason to avoid initiating statins; rather, the data suggest that in older populations, the absolute risk of an event is so high that the majority of these patients should be considered for therapy.^1,2

“Until now, many doctors have said, ‘Oh, if you came to 70, probably you don’t have a problem, so you should never have statins,’” Nordestgaard observed. “It’s actually the other way around. The absolute number…is such that there should be much more focus on giving statins to people above age 70.”¹

Lipoprotein(a): The "Once-in-a-Lifetime" Measurement

A major focus of the joint session was the clinical relevance of Lipoprotein(a) [Lp(a)]. Unlike low-density lipoprotein cholesterol (LDL-C), which fluctuates with diet and lifestyle, Lp(a) levels are largely genetically determined and remain stable throughout a person's life. The current EAS consensus identifies 50 mg/dL (105 nmol/L) as the threshold for clinically significant risk.^1,2

For the pharmacist, the measurement protocol is straightforward: every adult should have their Lp(a) measured at least once. However, Nordestgaard noted specific instances in which re-measurement is warranted, such as in women entering menopause or following an acute coronary syndrome or stroke, where levels may briefly dip before rebounding.¹

Although there are currently no approved, efficient Lp(a)-lowering drugs, the pipeline is robust. Pharmacists should prepare for a new era of injectables, with phase 3 trials for drugs like pelacarcin (offering an 80% reduction) and several siRNAs (achieving up to 98% reduction) expected to report results starting in late 2026.^1,3 Until then, the clinical strategy remains intensive LDL-C reduction and aggressive management of comorbid risk factors.

Beyond the Score: The Imaging Revolution

Incoming NLA President Dinesh Kalra, MD, MBA, FNLA, FACC, FAHA, FSCCT, FSCMR, addressed the limitations of traditional population-based risk tools like PREVENT or SCORE2, which often lack inputs for family history or Lp(a).

Kalra warned that by relying solely on simplified calculators, “[Clinicians] are sacrificing precision for simplicity.” He compared this to looking at a high body mass index and making assumptions without seeing the individual. To bridge this gap, he said imaging has moved to the forefront.¹

Coronary calcium scoring (CAC) is now a Class 1 recommendation in the 2026 ACC guidelines for borderline or intermediate-risk patients.^1,4 A CAC score above 1000 identifies a patient as extremely high risk, approximating secondary prevention, in which an LDL-C goal of under 55 mg/dL is advised.^1,4

However, Kalra warned that a "zero" CAC score in younger patients (ages 30–50) can be misleading, as it misses non-calcified plaque. This is where coronary CT angiography (CTA) is making its mark in prevention guidelines. CTA can identify lipid-rich, "vulnerable" plaques that have not yet calcified. This is vital information for pharmacists counseling patients on statin adherence; statins actually work to stabilize these plaques by shifting their morphology from non-calcified to a denser, more benign calcified state.

The Pharmacist as the "Laboratory of Change"

For pharmacists, this session serves as a call to action to move beyond simply filling prescriptions to becoming active participants in personalized risk assessment.

Pharmacists are uniquely positioned to:

1. Address Statin Hesitancy: Using imaging data—such as a high CAC score—to provide objective evidence of disease to hesitant patients.
2. Navigate the Pipeline: Managing the upcoming transition to highly potent, injectable Lp(a) therapies.
3. Monitor for Regression: Understanding that aggressive therapy (including statins, icosapent ethyl, and colchicine) can actually lead to plaque regression, a phenomenon now quantifiable via AI-assisted CTA.
4. Embrace New Modalities: Staying informed on emerging, radiation-free tools like retinal imaging and femoral ultrasound, which may soon provide 10-year ASCVD risk assessments in a primary care setting.

Kalra said he envisions a future in which coronary disease is staged by total plaque burden and therapies are titrated accordingly, “…just like we treat cancer today. We stage it, and then we titrate our therapies.” In this environment, the pharmacist remains the patient’s most accessible expert in the implementation of these life-saving strategies.

REFERENCES

1. Nordestgaard B, Kalra D, Ray K, Willard KE. Primary prevention of ASCVD: a joint session from the European Atherosclerosis Society and the National Lipid Association. Presented at: National Lipid Association 2026 Scientific Sessions. June 12, 2026. Chicago, IL.

2. Mach F, Koskinas KC, van Lennep JER, et al. 2026 focused update of the 2019 ESC/EAS guidelines for the management of dyslipidaemias: developed by the task force for the management of dyslipidaemias of the European Society of Cardiology (ESC) and the European Atherosclerosis Society (EAS). Eur Heart J. 2025;46(42):4359-4378. doi:10.1093/eurheartj/ehaf190

3. Assessing the impact of Lipoprotein(a) lowering with pelacarsen (TQJ230) on major cardiovascular events in patients with CVD (Lp(a)HORIZON). ClinicalTrials.gov identifier: NCT04023552. Updated May 6, 2026. Accessed June 12, 2026. https://clinicaltrials.gov/study/NCT04023552

4. Blumenthal RS, Morris PB, Gaudino M, et al. 2026 ACC/AHA/AACVPR/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of dyslipidemia: a report of the American College of Cardiology/American Heart Association joint committee on clinical practice guidelines. Circulation. 2026;153(17). doi:10.1161/CIR.0000000000001423