The 2025 VA/DoD lipid management guideline, released in December 2025 and summarised here, ran twelve key questions through GRADE and produced 24 recommendations. Several diverge from what other guidelines currently say, which is what makes it worth a generalist's attention.
For primary prevention, risk estimation moves to the PREVENT calculator, and the previous recommendation against routine lipid monitoring is withdrawn. Two risk-refinement tools are added: coronary artery calcium scoring where calculated risk is intermediate-to-high and the decision is genuinely uncertain, and one-time lipoprotein(a) measurement to identify patients whose risk the standard equations miss. Moderate-intensity statins remain the primary-prevention default at higher risk, and are now suggested for adults living with HIV even when calculated ten-year risk is low.
Secondary prevention shifts upward. For very high-risk atherosclerotic disease, the guideline now suggests combination therapy — high-intensity or maximally tolerated statin plus ezetimibe and/or a PCSK9 inhibitor — rather than statin escalation alone. For statin intolerance it names bempedoic acid, ezetimibe, fibrates or a PCSK9 monoclonal antibody as alternatives.
- Lipoprotein(a) is a once-in-a-lifetime test — order it, record it prominently, and do not repeat it.
- PREVENT includes kidney function and metabolic variables the pooled cohort equations did not, and generally returns lower estimates; a patient's risk category may change without their risk having changed.
- Neither PREVENT nor the pooled equations were derived in South Asian populations, where event rates at a given risk factor profile are higher — Indian guidance still advises treating at a lower threshold.
- Coronary artery calcium scoring is for resolving uncertainty, not for screening everyone at intermediate risk.
- Ezetimibe is cheap, available as a generic in India, and the easiest part of this update to act on immediately.
Why it matters
It changes which calculator sets the threshold for treating a healthy adult, and that threshold decides who takes a statin for thirty years.
Don't overread it
This is a US military and veterans guideline in a population that is largely male and older; it is not a global standard, and it does not supersede national guidance.
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