The American Heart Association (AHA), along with the American College of Cardiology (ACC), has released new guidelines on cholesterol management, marking a significant update in how cardiovascular risk is assessed and treated. The 2026 Guideline on the Management of Dyslipidemia is the first major ‘revision since 2018 and reflects evolving scientific evidence on lipid disorders, including LDL (“bad”) cholesterol and triglycerides.
Published jointly in the Circulation and the Journal of the American College of Cardiology, the updated recommendations incorporate research up to late 2024. The central message is clear: earlier screening, personalised treatment, and sustained management of cholesterol levels are essential to reducing lifetime cardiovascular risk—especially as heart disease increasingly affects younger populations.
“We know over 80% of cardiovascular disease is preventable, and elevated LDL (‘bad’) cholesterol is a major risk factor,” said Roger Blumenthal, MD, FACC, FAHA, chair of the guideline writing committee.
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He added that while lifestyle changes remain the first step, lipid-lowering medication may need to be introduced earlier if targets aren’t met, as maintaining lower LDL levels for longer significantly reduces the risk of heart attack and stroke.
New guidelines: What’s in for heart health?
A key feature of the updated guideline is the introduction of a new cardiovascular risk calculator known as Predicting Risk of Cardiovascular Disease Events (PREVENT). This tool is now recommended for primary prevention of atherosclerotic cardiovascular disease (ASCVD).
The PREVENT-ASCVD equations are designed for adults aged 30 to 79 years who do not have known cardiovascular disease or subclinical atherosclerosis and have LDL cholesterol levels between 70 and 189 mg/dL. These equations estimate both 10-year and 30-year risks of heart attack or stroke, enabling more precise and personalised treatment decisions.
This marks a shift from older models like the Pooled Cohort Equations, which, according to the guideline authors, tended to overestimate cardiovascular risk by as much as 40% to 50%.
The updated system classifies 10-year ASCVD risk into four categories: low (less than 3%), borderline (3% to less than 5%), intermediate (5% to less than 10%), and high (10% or higher). These categories guide clinicians in deciding whether to initiate statin therapy and how intensive treatment should be.
“With this new assessment tool, we can better estimate cardiovascular risk using health information already obtained during an annual physical—cholesterol, blood pressure readings and other personal information such as age and health habits—and then further personalize the risk score for each individual by looking at ‘risk enhancers,’ which can help guide the need for lipid-lowering therapy,” Blumenthal said.
The guidelines also highlight the importance of “risk enhancers,” which go beyond standard measurements. These include a family history of heart disease, chronic inflammatory conditions such as lupus or rheumatoid arthritis, and cardiometabolic conditions like obesity, diabetes, or chronic kidney disease.
Notably, the guideline acknowledges the role of ancestry, pointing out that individuals of South Asian or Filipino descent may face a higher risk of developing atherosclerosis. Reproductive factors such as early menopause, preeclampsia, and gestational diabetes are also recognised as important indicators in women.
Additional biomarkers, including lipoprotein(a) [Lp(a)], apolipoprotein B (apoB), high-sensitivity C-reactive protein (hsCRP), and elevated triglycerides, can further refine risk assessment and help tailor treatment strategies.
Additional tests
The new guideline recommends the selective use of additional diagnostic tests to improve cardiovascular risk assessment, particularly when there is uncertainty about a patient’s risk level.
One such test is the coronary artery calcium (CAC) scan, a non-invasive imaging tool that detects calcium buildup in the arteries. This test is recommended for men aged 40 and older and women aged 45 and older who fall into borderline or intermediate risk categories. The presence of coronary calcium indicates early plaque formation and supports the need for more aggressive cholesterol management.
The guideline suggests that individuals with any detectable coronary artery calcium should aim for LDL cholesterol levels below 100 mg/dL, with even lower targets for those with higher calcium scores.
Another key recommendation is the measurement of lipoprotein(a), or Lp(a), at least once in adulthood. Lp(a) levels are largely determined by genetics and remain stable over time. High levels, defined as 125 nmol/L or greater, are associated with a 1.4-fold increase in long-term cardiovascular risk, while levels of 250 nmol/L or higher may double the risk of heart attack or stroke. Since lifestyle changes have minimal impact on Lp(a), repeat testing is generally not required.
The guideline also highlights the role of apolipoprotein B (apoB), particularly in individuals with conditions such as Type 2 diabetes, high triglycerides, or cardiovascular-kidney-metabolic syndrome. ApoB may provide a more accurate assessment of residual cardiovascular risk in these populations, even when LDL cholesterol levels appear controlled.
Importantly, the new recommendations reintroduce specific LDL cholesterol targets. For primary prevention, individuals at borderline or intermediate risk should aim for LDL levels below 100 mg/dL, while those at high risk should target levels below 70 mg/dL. For patients with established cardiovascular disease and very high risk, the goal is even lower, below 55 mg/dL.
“In general, lower LDL is better, especially for people at increased risk for a heart attack or stroke,” said Pamela B. Morris, MD, FACC, FAHA. “Clinical trials have clearly demonstrated significant benefits for reduction in cardiovascular events when LDL-C levels are even lower than recommended in previous guidelines.”
When lifestyle changes and statin therapy are not sufficient, the guideline recommends adding non-statin treatments. These may include ezetimibe, bempedoic acid, or PCSK9 monoclonal antibodies, which are injectable therapies. Another injectable drug, inclisiran, is still being studied to determine whether its LDL-lowering effects translate into improved clinical outcomes.
The guideline also addresses hypertriglyceridemia, noting that lifestyle changes and statins remain the foundation of treatment. However, additional therapies may be required depending on an individual’s risk of cardiovascular disease or pancreatitis.
What are the recommendations for the young?
The updated guideline places strong emphasis on early intervention and tailored care for individuals at higher risk of heart disease, including younger populations.
One of the key recommendations is to initiate lipid-lowering therapy in adults aged 40 or older who have conditions such as chronic kidney disease (stage 3 or higher), HIV, or Type 1 or Type 2 diabetes. These groups are considered at elevated risk and may benefit from earlier treatment.
The guideline also advises continuing lipid-lowering therapy in patients undergoing cancer treatment, unless there are specific contraindications. At the same time, it recommends deferring most lipid-lowering medications during conception, pregnancy, and lactation due to potential safety concerns.
Importantly, the document highlights that the roots of cardiovascular disease often begin much earlier in life. High cholesterol can affect heart health even during childhood and adolescence, either due to genetic factors or lifestyle habits.
To address this, the guideline recommends cholesterol screening for all children between the ages of 9 and 11 who have not previously been tested. Early detection allows for timely intervention and helps guide long-term care decisions in collaboration with healthcare providers, parents, and caregivers.
“Implementation of this important new guideline by clinicians will be critical to reduce the burden of cardiovascular disease in the future,” Morris said.
This story is done in collaboration with First Check, which is the health journalism vertical of DataLEADS