My point is that the ratios are no longer considered relevant because we now understand better that HDL itself is not a particularly useful indication of anything - high HDL doesn't help you if your atherogenic particles are also high. All the clinical guidelines these days from places like the NLA, AHA, ACC focus basically entirely on lowering LDL (and will likely focus on lowering Lp(a) for relevant populations once drugs currently in the pipeline are available)
TG/HDL ratio is useful in one place, though - it's a reasonably good screen for insulin resistance if your labwork doesn't include more direct measures.
As for lifestyle intervention vs. medication - lifestyle changes are maybe enough if you're young. Like, in your early to mid 20s young. Plaque is a lifetime accumulation thing, and it's not like it waits until you're old to start accumulating, and while soft plaque can regress, it takes very low levels of LDL - sub 50, and similar with Lp(a). Not sure what the target is for cumulative ApoB. By the time you're diagnosed with ASCVD the treatment target for your atherogenic particles is lower than you can achieve with lifestyle changes alone, and requires medication. And there's a lot of data, such as was examined for the latest NLA recommendations that treatment targets should probably be even lower and people on statins or other therapy for them even sooner. We've relied on CAC as an indicator for a long time because they're relatively cheap and easy in comparison to things that actually pick up soft plaque, but soft plaque can and does still block your artery and can rupture, and even most people with dangerous levels of soft plaque will score a 0 on a CAC up until their 40s or 50s.
We also just know that lifestyle changes just don't work. People don't do them. So even if you're otherwise a candidate because of age, etc., the doctor should still almost certainly be recommending medication - and then if the patient really believes they can make the change, they can decline.
https://eas-society.org/wp-content/uploads/2022/11/2019_dysl...
https://www.jacc.org/doi/10.1016/j.jacc.2022.07.006
https://www.lipidjournal.com/article/S1933-2874(25)00317-4/f...
https://www.ahajournals.org/doi/10.1161/cir.0000000000000625
TG/HDL ratio is useful in one place, though - it's a reasonably good screen for insulin resistance if your labwork doesn't include more direct measures.
As for lifestyle intervention vs. medication - lifestyle changes are maybe enough if you're young. Like, in your early to mid 20s young. Plaque is a lifetime accumulation thing, and it's not like it waits until you're old to start accumulating, and while soft plaque can regress, it takes very low levels of LDL - sub 50, and similar with Lp(a). Not sure what the target is for cumulative ApoB. By the time you're diagnosed with ASCVD the treatment target for your atherogenic particles is lower than you can achieve with lifestyle changes alone, and requires medication. And there's a lot of data, such as was examined for the latest NLA recommendations that treatment targets should probably be even lower and people on statins or other therapy for them even sooner. We've relied on CAC as an indicator for a long time because they're relatively cheap and easy in comparison to things that actually pick up soft plaque, but soft plaque can and does still block your artery and can rupture, and even most people with dangerous levels of soft plaque will score a 0 on a CAC up until their 40s or 50s.
We also just know that lifestyle changes just don't work. People don't do them. So even if you're otherwise a candidate because of age, etc., the doctor should still almost certainly be recommending medication - and then if the patient really believes they can make the change, they can decline.