How would you counsel a patient on the risk/benefit profile of preventive management such as statin initiation if they have an elevated lipoprotein (a) level, markedly elevated LDL > 200 but a CAC score of 0 without other CV risk factors?   

Assuming this patient is over 45 years, and has tried dietary approaches to reduce cholesterol first, I would recommend a initiation of a moderate intensity statin to lower the risk of ASCVD events as the risk equation does not take into account the CAC score. 

Elevated Lp(a) levels have been associated with increased ASCVD risk hence it is a risk enhancer in primary ASCVd risk assessment. However, we are still awaiting RCT conclusively showing that reducing lp(a) with a drug leads to a reduction in hard cardiovascular outcomes. Until then, the jury is sti...