Lane 01 — Cardiometabolic.

Office BP — average of three seated, after five minutes quiet.

Minute 03 — Screening

The screening calendar in this lane is short and boring on purpose. We follow the U.S. Preventive Services Task Force A & B recommendations as the floor: lipid screening with a non-fasting lipid panel beginning at age 40 (B), blood-pressure screening at every visit (A), screening for prediabetes and type-2 diabetes in adults aged 35–70 with overweight or obesity (B), and screening for unhealthy alcohol use as a co-driver of MASLD (B). We don't add screens that the Task Force has graded I (insufficient evidence) or D (recommend against), and we tell you why when a member asks for one.

The screen we run that the Task Force does not strongly recommend is a baseline coronary artery calcium score (CAC) for members in the 40–75 window with a borderline-to-intermediate ten-year ASCVD risk (5–20%) and where the answer would change a statin decision. We follow the 2018 ACC/AHA Cholesterol Guideline and its 2022 expert-consensus pathway on CAC in primary prevention¹. The CT itself runs $109 cash at Essentia's imaging desk; the read is included.

Minute 14 — Doing the math out loud

The first appointment in this lane includes a tab in the chart we keep open during the visit: the ASCVD Risk Estimator Plus from the American College of Cardiology. We run the math with you, with your numbers, and we read the output aloud. The estimator is imperfect — the pooled cohort equations were derived in a population that does not look exactly like you, the model overestimates risk for some groups and underestimates it for others² — and we say so. The estimator's output is the start of a conversation, not the end of one.

If you want a printed copy of the numbers and the recommendation, we will print it. The printer is a Brother HL-L2390DW that lives behind the front desk. The printout will not be billable to anyone. It is paper.

Week 06 — Statins, ezetimibe, the new injectables

Where the math points to a benefit, we offer a statin first. Atorvastatin 20 mg is the most common starting dose in this practice; we dispense ninety tablets for $4.10. We follow up at six weeks with a repeat lipid panel and a check-in on muscle, sleep, and appetite — the three places statins most often complain. Where the LDL-C reduction is insufficient, we add ezetimibe 10 mg ($6.40 for ninety) before considering a PCSK9 inhibitor; for the small slice of the panel where a PCSK9 is the right answer, we use evolocumab (Repatha) and the manufacturer's copay program brings most members to a tolerable monthly cost on the high-deductible plan.

What we do not do is increase a statin dose past the patient's tolerance. The right statin is the one a person actually takes. A 2022 meta-analysis in Annals of Internal Medicine on statin-associated muscle symptoms found that the rates of "true" muscle pain attributable to statin (rather than nocebo or coincidence) were lower than is commonly reported³; we share that paper with members who have stopped a previous statin for muscle pain, and we re-challenge with rosuvastatin at a lower dose, supervised, before concluding the class is unworkable.

Week 12 — Blood pressure, measured properly or not at all

Almost every blood-pressure measurement that has ever been taken on you is wrong. Not by a small amount. By 5 to 15 mmHg, in either direction. The reasons are mechanical: the cuff was the wrong size, you had been sitting for less than five minutes, the room was cold, your bladder was full, you had crossed your legs, the arm was unsupported, or you had been talking. The American Heart Association's 2019 measurement scientific statement⁴ is unsparing on this point.

So the office BP at this practice is taken on a properly-sized cuff, on a bare arm, after five minutes of seated quiet, with feet flat and back supported, three readings taken one minute apart, and the first one discarded. The result is the average of readings two and three. If the office reading is borderline, we hand you a validated home cuff (Omron 3 Series HEM-7120, $39 at our cost; you keep it) and we ask for a week of paired readings, morning and evening. We treat the home log, not the office.

Week 24 — Prediabetes, with and without GLP-1

The current evidence base for prediabetes management runs through the Diabetes Prevention Program⁵: a structured lifestyle intervention reduced progression to type-2 diabetes by 58% over three years, more than metformin (31%), in a 3,234-person randomized trial. The original DPP curriculum is in the public domain. We use a modified version of it for members in the prediabetes window, with eight 45-minute coaching visits delivered by Nurse-Practitioner Armitage in the first six months, and a continuous glucose monitor for the first 28 days as a teaching aid.

Where lifestyle alone has not changed the numbers in twelve weeks and the member's BMI is > 30 with one cardiovascular risk factor, we offer semaglutide (Wegovy or Ozempic, depending on labeling) and we say plainly what we know and what we don't⁶. The cardiovascular outcomes are real. The musculoskeletal lean-mass loss is real. The weight rebound on cessation is real. We monitor with a quarterly visit and a DEXA scan at six months when warranted.

Year 01 — MASLD, the quiet one

Metabolic dysfunction-associated steatotic liver disease — what was called NAFLD until the AASLD's 2023 nomenclature change⁷ — is the cardiometabolic problem that travels under everyone's radar. We screen for it with a fasting metabolic panel, AST/ALT, and a FIB-4 score on every member with type-2 diabetes, BMI > 30, or persistent metabolic syndrome on the annual exam. Where the FIB-4 is > 1.3 (age < 65) or > 2.0 (age ≥ 65), we order a vibration-controlled transient elastography ("FibroScan") through the Aspirus St. Luke's hepatology clinic; where the FibroScan is in the F2-or-higher band, we refer to hepatology with a phone call.

A note on the continuous glucose monitor

We use Dexcom G7 sensors and Abbott Libre 3 sensors interchangeably depending on insurance coverage and supply. We do not believe a member without metabolic disease needs to wear a CGM continuously to "optimize" anything. We do use them as 28-day teaching tools in prediabetes; we do use them in the first three months of any new GLP-1 prescription; we do use them in any member whose A1c and self-monitored glucose readings disagree by more than 1.0%. They are an instrument, not a lifestyle.

Adjacent lanes that travel through cardiometabolic frequently: 07 · Sports & performance for endurance athletes whose lipid math reads differently than a sedentary middle-aged adult's, and 03 · Mental health because antidepressants — particularly mirtazapine and the older tricyclics — have weight and metabolic consequences worth tracking. Members can also see how this lane meets a real clinical case in case log 001.