Assessing familial risk without family history (+ 2nd hand smoke)

Medical Q&A [Moderated]
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All my blood work is pristine, but I have to work really hard to get good numbers. The “ideal” numbers from your article (based on “Summary of Treatment Targets” here: How-To Lower Your Heart Disease Risk: Action Plan for Cholesterol ) vary quite a bit depending on risk.

I can hit the low/average risk, but I’m adopted and don’t have a family history to draw from (though I have 23andMe genetic data which doesn’t really tell me much about FH). If someone comes to you and is adopted, what risk category could someone like me aim for, if everything is in order?

Also how does “Smoker” (Current/Former/Never) work if you have never smoked, but your parents were smokers as a kid? I was never a smoker but I dealt with 2nd hand smoke from 0-18 yr old.

My latest draw (Jun 2025)

Total: 192
LDL-C: 100
HDL-C: 79
Tris: 51
Non-HDL-C: 113
ApoB: 84
Lp(A): 7.8 (test was repeated, yes, it’s that low)

ACC puts my lifetime risk ( ASCVD Risk Estimator + ) at 36% which is much higher than I’d like. You have to get Total under 180 to 5% in that calculator (even if LDL stays the same) which seems wild to me because I could drop my HDL 13 pts and hit 5% lifetime without getting HDL below the ideal range (or dropping LDL which is surprising).

There’s the PREVENT calculator which has CVD at 5.3% in 30 yrs (ASCVD 3.1%, Heart Failure 3%). Is the ACC one dated, should I focus on PREVENT?

Basically I eat close to vegan and work really hard to keep SF <6% and fiber > 35g to hit those numbers (and I had to get my body weight down to like 174 at 6’1”, currently around 185). I’m okay with 3-5% 30 yr as a 40 yr old but 36% just feels like it’s going to be a real slog to get my total down to <180.

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Much of this is beyond the realm of what we can handle via the forum, as it is getting into very individualized / consult territory. With that said, I would likely approach this as an average-risk situation.

We don’t have any evidence to alter our approach/interpretation based on child smoke exposure.

I think these are acceptable lipid parameters for an average-risk person who is otherwise in good health. The ACC calculator you cite is indeed more dated compared with PREVENT, although even PREVENT has its limitations that have been discussed in the medical literature lately.

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