CLINICAL STATEMENTS AND GUIDELINES mg/dL (particularly when accompanied by persistently elevated triglycerides), and elevated Lp(a) denote high lifetime risk for ASCVD and favor initiation of statin therapy. The presence of family history of ASCVD, pre- mature menopause, and patients of South Asian race appear to convey a higher baseline risk and are stron- ger candidates for statin therapy. Conditions associated with systemic inflammation (chronic inflammatory dis- orders, metabolic syndrome, chronic renal disease, and elevated hsCRP) appear to predispose to atherothrom- botic events, which reasonably justifies statin therapy in intermediate-risk patients. 4.4.1.4. Coronary Artery Calcium Substantial advances in estimation of risk with CAC scoring have been made in the past 5 years. One pur- pose of CAC scoring is to reclassify risk identification of patients who will potentially benefit from statin therapy. This is especially useful when the clinician and patient are uncertain whether to start a statin. Indeed, the most important recent observation has been the finding that a CAC score of zero indicates a low ASCVD risk for the subsequent 10 years.S4.4.1.4-1 S4.4.1.4-8 Thus, measurement of CAC potentially allows a cli- nician to withhold statin therapy in patients show- ing zero CAC. There are exceptions. For example, CAC scores of zero in persistent cigarette smokers, patients with diabetes mellitus, those with a strong family history of ASCVD, and possibly chronic inflam- matory conditions such as HIV, may still be associated Neverthe- less, a sizable portion of middle-aged and older pa- tients have zero CAC, which may allow withholding of statin therapy in those intermediate risk patients who would otherwise have a high enough risk according to the PCE to receive statin therapy (Figure 2). 