Beyond lipids: a precision prevention blueprint for China's residual risk

Abstract

Despite achieving guideline-recommended lipid levels, patients with atherosclerotic cardiovascular disease (ASCVD) retain substantial residual risk arising from heterogeneous biological pathways, including persistent inflammation and genetically determined atherogenic susceptibility. High-sensitivity C-reactive protein (hs-CRP) provides a pragmatic measure of potentially modifiable inflammatory activity, whereas lipoprotein(a) [Lp(a)] identifies relatively stable, genetically mediated risk that is not adequately captured by standard lipid panels. The 2025 American College of Cardiology Scientific Statement highlights hs-CRP as a clinically useful inflammatory-risk marker and supports consideration of low-dose colchicine in appropriately selected secondary-prevention patients. The 2026 ACC/AHA multisociety dyslipidemia guideline further provides a Class I recommendation for once-in-a-lifetime Lp(a) measurement, creating a complementary multimodal framework for residual-risk assessment. In China, where cardiovascular disease accounts for a substantial proportion of deaths and the national cardiovascular burden continues to increase, implementation of this framework remains limited. Routine hs-CRP measurement is uncommon, cardiovascular use of colchicine remains negligible, and Lp(a) testing is still concentrated in selected tertiary centers. Emerging East Asian data and a recent Chinese expert advisory suggest that an hs-CRP threshold of approximately 1.0 mg/L may improve inflammatory-risk discrimination in Chinese patients with coronary artery disease; however, this threshold should not yet be interpreted as a stand-alone treatment threshold for colchicine. In this perspective, we compare international recommendations with current Chinese practice, analyze barriers related to infrastructure, safety, education, standardization, and evidence localization, and propose a multimodal implementation framework. Short-term priorities include once-in-a-lifetime Lp(a) measurement, context-specific hs-CRP assessment, intensified management of modifiable atherosclerotic risk factors, and carefully selected use of low-dose colchicine in secondary prevention. Elevated Lp(a) should prompt comprehensive risk-factor intensification and, when appropriate, family-based evaluation, but should not by itself constitute an indication for colchicine. Medium- and long-term priorities include pragmatic trials, real-world registries, assay standardization, cost-effectiveness studies, and policy initiatives to integrate residual-risk assessment into Chinese cardiovascular prevention pathways.