Guideline Update

ACC/AHA Issue 2026 Cholesterol Guideline With Lower LDL Targets, Expanded Risk Assessment

Edited by:
Anthony Calabro, MA

Key Highlights

  • A new PREVENT-ASCVD calculator replaces prior risk models and guides 10- and 30-year ASCVD risk–based treatment decisions
  • Earlier and more intensive lipid-lowering strategies are recommended, including pharmacotherapy when lifestyle changes are insufficient.
  • LDL-C targets were reintroduced and lowered (<100 mg/dL, <70 mg/dL, and <55 mg/dL based on risk).
  • The new guidelines expand use of risk-enhancing biomarkers, including routine lipoprotein(a) measurement and selective apoB testing.

The American College of Cardiology (ACC), American Heart Association (AHA), and 9 partnering organizations have released an updated guideline on the management of dyslipidemia, providing a comprehensive approach to lipid assessment and treatment aimed at reducing atherosclerotic cardiovascular disease (ASCVD) risk.

Dyslipidemia, defined as abnormal levels of lipids or lipoproteins, affects a substantial portion of the population, with approximately 1 in 4 US adults having elevated low-density lipoprotein cholesterol (LDL-C), a key contributor to cardiovascular risk.

“We know that each of these lipid abnormalities can contribute to the buildup of fatty deposits in the arteries, and that leads to both a higher risk of heart attack and stroke,” Roger Blumenthal, MD, FACC, FAHA, chair of the guideline writing committee said in a press release. “And dyslipidemia is a major modifiable risk factor for heart disease, just like high blood pressure and cigarette smoking are.”

Dr Blementhal also noted that dyslipidemia carries greater prognostic significance in patients with comorbid conditions such as hypertension, chronic kidney disease, HIV infection, and cancer.

The guideline introduces the PREVENT-ASCVD risk calculator for primary prevention in adults aged 30 to 79 years with LDL-C levels of 70–189 mg/dL and no known ASCVD. The tool estimates both 10- and 30-year risk and replaces earlier models that overestimated 10-year risk by approximately 40% to 50%. Patients are categorized as low (<3%), borderline (3% to <5%), intermediate (5% to <10%), or high (≥10%) risk, with these categories used to guide decisions on initiating and intensifying lipid-lowering therapy. Additional risk-enhancing factors, including family history, chronic inflammatory conditions, cardiometabolic disease, higher-risk ancestry, and reproductive history, may further inform treatment decisions.

Lifestyle modification, including weight management, physical activity, tobacco avoidance, and healthy sleep, remains the foundation of care. When lipid levels remain above recommended thresholds, pharmacologic therapy is recommended. Statins are first-line therapy, with additional agents such as ezetimibe, bempedoic acid, and PCSK9 inhibitors used when further LDL-C reduction is needed. The guideline further emphasizes reducing cumulative lifetime exposure to LDL-C, with earlier and sustained lipid lowering associated with greater reductions in ASCVD risk. The guideline also notes that cardiovascular risk begins early in life and recommends cholesterol screening for children aged 9 to 11 years to help identify risk and guide management.

The guideline also reintroduces LDL-C treatment goals. For primary prevention, LDL-C targets are <100 mg/dL for individuals at borderline or intermediate risk and <70 mg/dL for those at high risk. For secondary prevention in very high-risk individuals, a target of <55 mg/dL is recommended. These targets are based on clinical trial evidence demonstrating reductions in cardiovascular events at lower LDL-C levels.

Additional testing is recommended to refine risk assessment. Lipoprotein(a) [Lp(a)] should be measured at least once in adulthood; levels ≥125 nmol/L (≥50 mg/dL) are associated with increased ASCVD risk, and levels of 250 nmol/L are associated with at least a twofold increased long-term risk. Apolipoprotein B (apoB) measurement may be considered in select patients, particularly those with metabolic conditions or residual risk despite achieving LDL-C goals.

Selective use of coronary artery calcium (CAC) scoring is recommended for men aged 40 years and older and women aged 45 years and older with borderline or intermediate risk when treatment decisions remain uncertain. The presence of CAC supports initiation or intensification of lipid-lowering therapy and may inform more aggressive LDL-C targets based on plaque burden.

The guideline also includes recommendations for the management of hypertriglyceridemia, for which lifestyle modification and statin therapy remain first-line, with additional treatment based on ASCVD and pancreatitis risk. Additional guidance is provided for patients with conditions that increase cardiovascular risk, including diabetes, chronic kidney disease, HIV, and cancer.

Reference
American College of Cardiology/American Heart Association. ACC/AHA issue updated guideline for managing lipids, cholesterol. News release. March 13, 2026. https://newsroom.heart.org/news/accaha-issue-updated-guideline-for-managing-lipids-cholesterol