Author: Neel Achary

The New Cholesterol Guideline What to Know

For the first time since 2018, a clinical guideline from the American College of Cardiology and the American Heart Association for screening and managing blood cholesterol levels has been updated and jointly published in the Journal of the American College of Cardiology and Circulation. The new guideline will be discussed March 28 at the American College of Cardiology’s 75th Annual Scientific Session in New Orleans.

The guideline’s release also ran a week before a paper titled “The ABCs of Cardiovascular Disease Prevention: Communicating What We Know in 2026” published in the American Journal of Preventive Cardiology.

The new guideline focuses on recommendations to lower elevated levels of low-density lipoprotein (LDL) cholesterol, often referred to as bad cholesterol, as well as other types of lipids, or fats such as lipoprotein(a), or Lp(a), circulating in the bloodstream. It also emphasizes the importance of earlier screenings, especially for those with a family history of heart disease, and more personalized risk estimations, such as for those with underlying medical conditions, to support shared decision-making between clinicians and patients.

“We know that lower LDL cholesterol levels are better when it comes to reducing the risk of heart attacks, strokes and congestive heart failure,” says Roger S. Blumenthal, M.D., chair of the guideline writing committee and director of the Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease. “We also know that bringing elevated lipids and blood pressure down in young adults supports optimal heart and vascular health throughout a person’s life.”

The updated guideline comes at a time when studies show that 1 in 4 U.S. adults have elevated LDL cholesterol (LDL-C), a risk factor for atherosclerosis (the narrowing or hardening of the arteries). The excess accumulation of certain lipids can fuel the growth and development of plaque in the arteries. Moderate atherosclerotic plaque in heart arteries can block blood flow. Other factors, such as age and other cardiovascular risks, can predispose plaque to break off — setting the stage for a heart attack, stroke or need for urgent interventions to restore circulation.

Blumenthal emphasizes that foundational principles known to support heart-healthy living and keep cholesterol levels within a normal range remain the same. These include eating a heart-healthy diet, engaging in regular, brisk physical activity, avoiding tobacco, getting enough sleep and maintaining a healthy weight. He underscores the fact that about 80% to 90% of  cardiovascular disease is at least in part attributable to modifiable risk factors, which is why focusing on lifestyle interventions should be a first or foundational approach.

A change in the new cholesterol guideline is a call for earlier screenings and more use in assessing risk of a person’s family history of atherosclerosis, underlying medical conditions, like rheumatoid arthritis, and lifetime risks, such as early menopause or having certain pregnancy complications, such as preeclampsia or gestational diabetes, to inform treatment decisions.

For example, the new guideline recommends that people with a history of familial hypercholesterolemia, or inherited levels of extremely high LDL-C, are now advised to be  screened earlier in life — starting in childhood at around age 9 (or earlier). The guideline also recommends one-time screenings for levels of Lp(a), which is often related to genetic risk and can increase a person’s risk for heart disease by about 40% at levels of 125 nanomoles per liter and a doubling of risk at levels of 250 nanomoles per liter.

Another update includes using a new risk calculator for 10- and 30-year risk estimates for heart attacks and stroke. Previously, the pooled cohort equation was used to predict 10-year risks for heart disease for people age 40 and older. That calculator contained baseline risks, such as age, cholesterol levels and blood pressure. The updated calculator, called Predicting Risk of Cardiovascular Disease EVENTs (PREVENT), incorporates additional data, including indicators of blood sugar and kidney health, to estimate these risks and is recommended for use starting at age 30. The PREVENT score is based on data gathered on 6.6 million individuals; the previous calculator was based on 26,000 people.

“Shifting the paradigm toward proactive prevention strategies earlier in life can meaningfully change the trajectory of cardiovascular disease and lead to better health outcomes for people decades later,” says Seth Martin, M.D., M.H.S., a cardiologist, member of the guideline writing committee and director of the Advanced Lipid Disorders Program and Digital Health Lab at the Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease. 
To further support personalized risk assessment, the guideline also provides recommendations to help clinicians account for atherosclerosis “risk enhancers.”

 For example, if a person has borderline to intermediate risks for atherosclerosis, clinicians may selectively use additional tests to guide decision-making. These include assessing circulating levels of inflammation in the bloodstream known as high-sensitivity C-reactive protein (hsCRP). Lp(a) elevation may also be considered, as can other factors, such as family history of early cardiovascular disease and higher-risk ancestry. In addition to risk enhancers, the updated guideline gives multiple recommendations for the use of coronary artery calcium scanning to detect deposits of calcium in the arteries, representing plaque, to help personalize treatment decisions.

The updated guideline includes recommendations about treatment decisions for pregnant or lactating women, adults age 75 and older and those living with underlying conditions, such as diabetes, late-stage chronic kidney disease and HIV infection, as well as people undergoing treatment for cancer.
The new guideline provides details about statin therapy, along with updated information about other lipid-lowering treatments, such as ezetimibe, bempedoic acid and injectable PCSK9 monoclonal antibody treatments. The latter are recommended for people who may not respond well to statin therapy, or who may need a combination of treatments to lower their LDL-C levels.

Optimal LDL-C levels for people without cardiovascular disease are considered below 100 mg/dL. The updated guideline recommends that people with intermediate risks lower LDL-C levels to below 70 mg/dL. People with higher risks should bring LDL-C levels to below 55 mg/dL. In addition to the LDL-C goals, the guideline provides recommendations for non-HDL-C and apolipoprotein B, a molecule attached to cholesterol.

In an editorial accompanying the new guideline, Blumenthal and the vice-chair of the 2026 ACC/AHA/Multisociety Dyslipidemia Guideline predicted that future guidelines would also likely recommend that people with at least moderate atherosclerosis aim to lower LDL-C levels to below 55 mg/dL. The 2026 guideline was developed before the results of the clinical trial VESALIUS-CV published in the New England Journal of Medicine. In that trial, researchers found benefits of targeting these ranges (by using a combination of lipid-lowering therapies).

The 2026 Guideline on the Management of Dyslipidemia is a report of the American College of Cardiology and the American Heart Association Joint Committee on Clinical Practice Guidelines. It was developed in collaboration with and endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation, the Association of Black Cardiologists, the American College of Preventive Medicine, the American Diabetes Association, the American Geriatrics Society, the American Pharmacists Association, the American Society for Preventive Cardiology, the National Lipid Association and the Preventive Cardiovascular Nurses Association.

Blumenthal is the chair of the guideline writing committee. Martin is a committee member. Other authors of the guideline writing committee include Morris P.B., Gaudino M., Johnson H.M., Anderson T.S., Bittner V.A., Blankstein R., Brewer L.C., Cho L., de Ferranti S.D., Gianos E., Gluckman T.J., Gradney K., Isiadinso I., Lloyd-Jones D.M., Marrs J.C., McLain K.H., Mehta L.S., Mora S., Mulugeta W.M., Natarajan P., Navar A.M., Orringer C.E., Polonsky T.S., Reynolds H.R., Saseen J.J., Shapiro M.D., Soffer D.E., Tynes S.A., Villavaso C.D., Virani S.S. and Wilkins J.T..

Martin disclosed prior research consultations for Amgen, Arrowhead Pharmaceuticals, AstraZeneca, Kaneka Pharma, Merck, NewAmsterdam Pharma, Novartis and Sanofi, and  ownership in Corrie Health. Blumenthal and the majority of the writing committee had no relationships with industry.