Advanced Tools Decision Flowchart

Visual guide for determining which advanced diagnostic tool(s) to order based on clinical scenario. See 06 — Advanced Tools for detailed protocols.

Start with the clinical question in Part 1, then follow the chart for that test. Every pathway ends the same way: interpret the result in the context of the full risk profile and update the risk category and treatment plan.

Entry point or goal reached Assessment step Decision question Treatment started or test ordered Caution: needs further evaluation High risk: urgent or aggressive action Labs, scheduling, or administrative step Continues in another chart on this page On a small screen, swipe sideways on a chart to see all of it.

Part 1 — What Is the Clinical Question? 

flowchart LR
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    Q1{What is the<br>clinical question?}

    Q1 -->|Atherogenic particle<br>burden| P2[Part 2:<br>ApoB]:::link
    Q1 -->|Inherited risk<br>factor| P3["Part 3:<br>Lp(a)"]:::link
    Q1 -->|Atherogenic dyslipidemia<br>characterization| P4[Part 4:<br>NMR LipoProfile]:::link
    Q1 -->|Subclinical<br>atherosclerosis| P5[Part 5:<br>Imaging]:::link
    Q1 -->|Symptomatic<br>coronary evaluation| P6[Part 6:<br>CCTA]:::link

Part 2 — ApoB 

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    APOB_Q{Scenario?} -->|LDL-C / non-HDL-C<br>discordance| APOB[Order ApoB]:::treat
    APOB_Q -->|MetSyn or T2DM| APOB
    APOB_Q -->|TG 150–499 mg/dL| APOB
    APOB_Q -->|At/near LDL-C goal,<br>assess residual risk| APOB
    APOB_Q -->|On-treatment<br>monitoring| APOB
    APOB --> NEXT[Interpret results in<br>context of full risk profile;<br>update risk category<br>and treatment plan]:::entry

Part 3 — Lp(a) 

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    LPA_Q{"Lp(a) Previously<br>Measured?"} -->|No| LPA["Order Lp(a)<br>nmol/L"]:::treat
    LPA_Q -->|Yes| LPA_DONE[Use Prior Result<br>No repeat needed]:::admin
    LPA --> NEXT[Interpret results in<br>context of full risk profile;<br>update risk category<br>and treatment plan]:::entry

Part 4 — NMR LipoProfile 

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    NMR_Q{Scenario?} -->|TG 150–499 +<br>suspected atherogenic<br>dyslipidemia| NMR[Order Labcorp<br>NMR LipoProfile]:::treat
    NMR_Q -->|MetSyn / T2DM<br>with discordant<br>LDL-C vs ApoB| NMR
    NMR_Q -->|Persistent events<br>despite LDL-C<br>at target| NMR
    NMR_Q -->|Suspected insulin<br>resistance| NMR
    NMR --> NEXT[Interpret results in<br>context of full risk profile;<br>update risk category<br>and treatment plan]:::entry

Part 5 — Imaging (CAC Score or Carotid Duplex) 

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    IMG_Q{Patient<br>Category?}
    IMG_Q -->|Borderline/intermediate<br>risk, statin decision<br>uncertain| CAC[Order CAC<br>Score]:::treat
    IMG_Q -->|Cervical bruit,<br>prior stroke/TIA,<br>known stenosis| CAROTID[Order Carotid<br>Duplex]:::treat
    IMG_Q -->|Established ASCVD<br>or committed to<br>high-intensity statin| NOIMG[No imaging<br>needed for<br>risk stratification]:::admin
    CAC --> NEXT[Interpret results in<br>context of full risk profile;<br>update risk category<br>and treatment plan]:::entry
    CAROTID --> NEXT

Part 6 — CCTA 

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    CCTA_CRIT[CCTA criteria:<br>• Symptomatic<br>• Low-intermediate pre-test probability<br>• Not in AFib<br>• BMI ≤ 40<br>• No prior stents]:::assess
    CCTA_CRIT --> CCTA_Q{Meets ALL<br>criteria?}
    CCTA_Q -->|Yes, all met| CCTA[Order CCTA]:::treat
    CCTA_Q -->|No, ≥ 1 not met| NOCCTA[CCTA Not Appropriate<br>Consider alternatives]:::caution
    CCTA --> NEXT[Interpret results in<br>context of full risk profile;<br>update risk category<br>and treatment plan]:::entry

Quick Reference: When to Order Each Test

Test Order When Do NOT Order When
ApoB New patients; discordance; MetSyn/DM; at/near target; monitoring — (broadly useful)
Lp(a) All new patients (one-time) Already measured (genetically determined)
NMR LipoProfile Atherogenic dyslipidemia suspected; TG 150–499; discordant results; persistent events Routine screening; clear-cut cases
CAC Score Borderline/intermediate risk; statin decision uncertainty Established ASCVD; age < 40 or > 75; prior stents/CABG
Carotid Duplex Bruit; prior stroke/TIA; known stenosis surveillance Routine screening without clinical indication
CCTA Symptomatic + low-intermediate risk + sinus rhythm + BMI ≤ 40 + no stents Asymptomatic; AFib; BMI > 40; prior stents

Version History

Version Date Description
1.0.0 2026-03-30 Initial release
1.1.0 2026-09-29 Split into smaller charts so text renders at full size; fixed line breaks that printed as literal escape codes; accessible color palette and shared legend

© 2026 The Sandusky Dyslipidemia Model. For clinical decision support only. Not a substitute for clinical judgment.