The US Department of Veterans Affairs and Department of Defense updated their 2020 lipid guideline in December 2025, with 24 GRADE-rated recommendations; this Annals synopsis highlights what is new or differs from other guidelines.
For primary prevention it adopts the PREVENT calculator, removes the previous advice against routine lipid monitoring, suggests coronary artery calcium scoring where calculated risk is intermediate to high and the decision is uncertain, and recommends one-time lipoprotein(a) testing to identify enhanced risk. Moderate-intensity statins remain the default for higher-risk patients and should be considered at intermediate risk; adults living with HIV are now suggested a moderate-intensity statin even at low calculated risk.
For secondary prevention the guideline moves towards more intensive therapy. Very high-risk patients with atherosclerotic disease are suggested combination therapy — high-intensity or maximally tolerated statin plus ezetimibe and/or a PCSK9 inhibitor. For statin intolerance it lists bempedoic acid, ezetimibe, fibrates and PCSK9 antibodies.
For Indian practice, PREVENT was not derived in South Asian populations and may underestimate risk, but the move to Lp(a) testing and early statin–ezetimibe combination translates directly and affordably.
- Measure lipoprotein(a) once in every adult having a cardiovascular risk assessment.
- Consider coronary calcium scoring when calculated risk is intermediate and the statin decision is genuinely uncertain.
- Offer a moderate-intensity statin to adults living with HIV, even when their calculated 10-year risk is low.
- In very high-risk patients with atherosclerotic disease, add ezetimibe to a maximally tolerated statin rather than waiting.
- For true statin intolerance, use ezetimibe, bempedoic acid or a PCSK9 inhibitor rather than no therapy.
Why it matters
It moves combination lipid-lowering from an escalation step to a starting point for the highest-risk patients.
Don't overread it
The PREVENT calculator has not been validated in South Asian populations, where it may underestimate risk.
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