The following question refers to Figures 6-8 from Sections 3.2 of the 2021 ESC CV Prevention Guidelines. The question is asked by student Dr. Hirsh Elhence, answered first by Ohio State University Cardiology Fellow Dr. Alli Bigeh, and then by expert faculty Dr. Eugene Yang.Dr. Yang is Professor of Medicine at the University of Washington where he is also the Medical Director of the Eastside Specialty Center and the co-Director of the Cardiovascular Wellness and Prevention Program. Dr. Yang is former Governor of the ACC Washington Chapter and as well as former Chair of the ACC Prevention of CVD Section.  The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association.Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values. Question #31 The 2021 ESC CV Prevention guidelines recommend a stepwise approach to risk stratification and treatment options. What is the first step in risk factor treatment regardless of past medical history, risk factors, or established ASCVD?AInitiate statin for goal LDL <100 mg/dlBAssess family history of premature CVDCCounsel on ketogenic dietDStop smoking and lifestyle recommendations Answer #31 ExplanationThe correct answer is D – stop smoking and lifestyle recommendations. Smoking cessation and lifestyle modifications are recommended for everyone across the spectrum of ASCVD risk including for both primary and secondary prevention (Class 1). It is worth noting that many patients can move themselves towards a lower risk category without taking drugs just by stopping smoking.Option A is incorrect. While initiating statin therapy for goal LDL <100 mg/dL may be an appropriate treatment option for some patients, it is not the first step per the “stepwise approach” recommended in the ESC guidelines. Whether or not to initiate a statin depends on a multitude of factors including estimated 10-year CVD risk, age, comorbidities, established ASCVD, and patient preference. The first step for patients with established ASCVD includes LDL-C reduction to goal <70 mg/dL (class I) with intensification to a goal LDL-C <55mg/dL based on residual 10-year CVD risk, lifetime CVD risk and treatment benefit, comorbidities, frailty, and patient preference.  Primary prevention of ASCVD first targets LDL-C goal <100 (class IIa) in appropriately selected patients.Option B is incorrect. While assessing family history of premature CVD should be part of an initial evaluation and certainly considered a risk enhancing factor, it is not a modifiable risk factor with regards to treatment.Option C is incorrect. A ketogenic diet is not endorsed nor recommended by ACC/AHA or ESC.Studies have shown the benefit of a stepwise approach to treatment intensification. Attainment of treatment goals is similar, side effects are fewer, and patient satisfaction is significantly greater with such an approach. It is not recommended to stop assessment of treatment goals after the first step.Main TakeawayA stepwise approach to treatment intensification is recommended. The first steps for all patients are to stop smoking and institute lifestyle recommendations.Guideline Loc.·       3.2.3 Figures 6-8 CardioNerds Decipher the Guidelines - 2021 ESC Prevention SeriesCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor RollCardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron!