New ACC/AHA Dyslipidemia Guidelines Emphasize Earlier Intervention and Return to LDL-C Targets

The American College of Cardiology (ACC) and the American Heart Association (AHA), in conjunction with 9 other medical organizations, have released the 2026 Updated Guidelines for Dyslipidemia and Atherosclerotic Cardiovascular Disease (ASCVD) Management.¹

Published simultaneously on March 13, 2026 in the Journal of the American College of Cardiology and Circulation, the updated document serves as a comprehensive resource for primary care physicians (PCPs) to navigate the complexities of lipid management in a population where 1 in 4 adults presents with elevated low-density lipoprotein cholesterol (LDL-C). The last major comprehensive update regarding blood cholesterol management was published in November 2018.^2,3

“We know 80% or more of cardiovascular disease is preventable and elevated LDL cholesterol, sometimes referred to as ‘bad’ cholesterol, is a major part of that risk,” said Roger Blumenthal, MD, chair of the guideline writing committee, director of the Johns Hopkins Ciccarone Center for the Prevention of Heart Disease.¹

A cornerstone of the 2026 update is the formal recommendation to transition from the Pooled Cohort Equations to a more contemporary risk assessment tool: the Predicting Risk of Cardiovascular Disease EVENTs (PREVENT) equations. Evidence suggests older risk scores overestimated 10-year ASCVD risk by approximately 40% to 50%. PREVENT equations were first used in 2023 to replace the 2013 Pooled Cohort Equations used to assess cardiovascular health.^2,4

PREVENT-ASCVD equations are validated for adults aged 30 to 79 years without clinical or subclinical atherosclerosis who have LDL-C levels between 70 and 189 mg/dL. Notably, the tool provides both 10-year and 30-year risk estimates, facilitating a more nuanced discussion regarding lifetime exposure to unhealthy lipids. The guidelines categorize 10-year risk into 4 tiers: low (<3%), borderline (3% to <5%), intermediate (5% to <10%), and high (≥10%). These categories are intended to guide the initiation and intensity of statin therapy.^2,3

“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.¹

In a significant shift from some previous iterations focused primarily on statin intensity, the 2026 guidelines reintroduce specific LDL-C and non-high-density lipoprotein cholesterol (non-HDL-C) targets. For primary prevention, clinicians should aim for an LDL-C <100 mg/dL in patients at borderline or intermediate risk, and <70 mg/dL for those at high risk. For secondary prevention in individuals at very high risk of ASCVD events, the target is tightened to <55 mg/dL.^2,3

While statins remain the first-line pharmacological treatment, the guidelines outline an evidence-based hierarchy for non-statin add-on therapies, including ezetimibe, bempedoic acid, and PCSK9 monoclonal antibodies. Inclisiran is identified as an injectable option, though the committee noted clinical trials are ongoing to confirm its impact on cardiovascular outcomes.

The guidelines encourage the use of "risk enhancers" and additional biomarkers when clinical uncertainty remains. Key enhancers include family history of premature ASCVD, chronic inflammatory conditions (e.g., lupus, rheumatoid arthritis), and reproductive markers such as preeclampsia or early menopause.

Specific testing recommendations include:

• Lipoprotein(a): Should be measured at least once in adulthood, as levels are genetically determined and highly stable. Levels ≥125 nmol/L (or ≥50 mg/dL) indicate a 1.4-fold increased risk of ASCVD.
• Apolipoprotein B (apoB): May be more accurate than LDL-C for assessing residual risk in patients with type 2 diabetes, high triglycerides, or cardiovascular-kidney-metabolic syndrome.
• Coronary Artery Calcium (CAC) Scoring: Selective use of non-contrast CAC scans is recommended for men ≥40 and women ≥45 with borderline or intermediate risk. The presence of any calcium supports an LDL-C goal of <100 mg/dL, with lower targets for higher calcium burdens.

Special clinical considerations are provided for high-risk cohorts. Clinicians are advised to initiate lipid-lowering therapy for patients aged 40 or older with chronic kidney disease (stage 3 or higher), HIV, or diabetes. Furthermore, the guidelines highlight a life-course approach to lipid management, recommending universal cholesterol screening for children between ages 9 and 11 to address inherited conditions or lifestyle-induced elevations early in life.

References

1. American Heart Association. Published March 13, 2026. Accessed March 13, 2026. https://newsroom.heart.org/news/accaha-issue-updated-guideline-for-managing-lipids-cholesterol
2. American College of Cardiology; American Heart Association. 2026 ACC/AHA updated guidelines for dyslipidemia and ASCVD management. J Am Coll Cardiol. Published online March 13, 2026.
3. Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019;139(25). doi: https://doi.org/10.1161/cir.0000000000000624
4. American Heart Association PREVENT TM Equations Frequently Asked Questions • What Are the PREVENT Equations? • What Risk Estimates Do the PREVENT Equations Provide? • How Do the PREVENT Equations Differ from the Pooled Cohort Equations? • Which Guidelines Currently Include the PREVENT Equations?; 2026.