Jorge A. Pérez-Coaguila, Servicio de Cardiología Perioperatoria, Instituto Nacional Cardiovascular INCOR, EsSalud, Lima, Perú
For decades, dyslipidemia management centered on quantifying LDL cholesterol. Current evidence raises a broader question: how much atherogenic burden has the patient accumulated over their lifetime, and how much cardiovascular risk can be modified starting today? In Peru, dyslipidemias coexist with arterial hypertension, diabetes, obesity, and smoking, within a context of epidemiological and nutritional transition. A national meta-analysis reported a pooled prevalence of hypercholesterolemia of 25.93%, and local registries show that dyslipidemia is present in 22.8%-52.9% of patients with acute myocardial infarction, with a national upward trend in the latter. Recent international documents – including the 2025 ESC/EAS focused update and the new 2026 ACC/AHA guidelines – consolidate a paradigm shift: from isolated LDL cholesterol measurement toward a comprehensive assessment of atherogenic burden and residual risk. Non-HDL cholesterol and apolipoprotein B better reflect the number of circulating atherogenic particles, even in patients with controlled LDL cholesterol. Lipoprotein(a), which is genetically determined and stable over time, identifies substantial residual risk despite statin therapy. Triglycerides, beyond their role as residual risk markers, warn of pancreatitis risk at extreme concentrations. Vascular imaging, particularly coronary calcium, allows risk reclassification prior to a clinical event. This manuscript introduces a series aimed at translating this evidence into practical stratification strategies, therapeutic goals, drug selection, and secondary prevention applicable to the Peruvian healthcare context.
Keywords: LDL cholesterol. Atherogenic burden. Apolipoprotein B. Lipoprotein(a). Triglycerides. Dyslipidemias in Peru.