Takeaways from the Updated Cholesterol Guidelines: What Should Providers Know?

With the release of the 2026 American College of Cardiology/American Heart Association Multisociety Guideline on the Management of Dyslipidemia, patients and providers are entering a new era of early interventions and more intensive lipid-lowering strategies. The updated recommendations, which replace the 2018 guidelines, emphasize a return to simplified goals while providing clinicians with a myriad of options for managing individuals with diverse needs and different levels of cardiovascular risk. At the 75th Annual Scientific Session of the American College of Cardiology, in New Orleans, experts in preventive cardiology discussed strategies for translating these recommendations into successful treatment strategies. 

Simplified Goals 

“Probably the biggest takeaway [of these guidelines] is simplified, easy to implement goals that hopefully we can now translate into clinical practice,” according to Ann Marie Navar, MD, associate professor at UT Southwestern Medical Center, in Dallas, Texas. “The reality is that a vast majority of patients who were eligible 6 months ago are still eligible for statins. We know that over half of people with atherosclerotic cardiovascular disease (ASCVD) are not getting to low-density lipoprotein cholesterol (LDL-C) goals of 70 mg/dL. While we fuss about 55 mg/dL for everybody versus some [individuals], we are not getting there for most patients.” 

Practical ways for implementing these goals in clinics may include updating risk calculators in the electronic health records to PREVENT, a comprehensive score that estimates the 10-year and 30-year risk for ASCVD and cardiovascular death and can guide preventive strategies. Building flags into the electronic health record to indicate enhancers of cardiovascular risk may also help optimize prevention, the speaker said. 

While the standardized risk categories provide a useful guide for clinicians, the goals of therapy should be tailored to individual patients’ needs and estimated risk, to ensure adherence to therapy. “The general principle is that we want to match the intensity of therapy with the level of risk,” said co-panelist Ron Blankstein, MD, professor of medicine at Brigham and Women’s Hospital in Boston. “We are trying to simplify [the algorithm] by having simpler goals, and those are repeated throughout the guidelines, whether it’s the level of risk or the amount of atherosclerosis on imaging. Hopefully, those are goals that are easy to remember. We now have therapies that are much more intense and more costly, so they are not going to be for everyone.” The updated recommendations provide guidance on the frequency of LDL-C measurements after initiating or changing therapy, enabling providers to adjust treatment algorithms based on ongoing monitoring. 

When managing older adults, polypharmacy adds another layer of complexity to treatment regimens. “One thing to [consider], especially in geriatric cardiology, is pill burden,” said Roger Blumenthal, MD, professor of cardiology at The Johns Hopkins University School of Medicine in Baltimore, Maryland. “Sometimes we need to remember that our patients take multiple medications, so a clinician-patient discussion regarding multiple medications is very important.” As for patients at a lower 10-year risk for ASCVD who may not want lipid-lowering therapy, looking at the 30-year risk can be more meaningful and can guide clinical decision-making, Blumenthal added. Blumenthal served as the Chair of the Writing Committee for the 2026 dyslipidemia guidelines. 

“When there is uncertainty, that’s exactly where calcium scoring fits in,” Blankstein added. “Once we know there is atherosclerosis, we tend to be more aggressive when it comes to treatment, and not just with statins, but with many other preventive therapies.” Blankstein, who co-authored the guidelines, noted that successful implementation means getting patients on board with the recommendations. “We are in an era now when implementation means not just educating clinicians but directly [educating] patients,” he said. “This is a guideline about prevention and so many patients have taken control, so [disseminating] information directly to the patients via a lot of different channels is so important when it comes to prevention.”

The Lower, the Better 

The 2026 ACC/AHA guidelines for lipid management emphasize a "lower for longer" approach to LDL-C levels to enhance cardiovascular protection. Key targets include keeping LDL-C levels below 100 mg/dL for low-risk individuals, below 70 mg/dL for high-risk patients, and under 55 mg/dL for patients at very high risk for ASCVD. “We know that the magnitude of the benefit for LDL cholesterol lowering is proportional to the degree of lowering,” Navar noted. “There does not seem to be a level below which LDL cholesterol lowering is not beneficial.” Patients at high risk for ASCVD should aim for any LDL-C level under 55 mg/dL. Preventive strategies should also be considered for individuals at lower risk, the “over-achieving patients” who do not meet the criteria for statin therapy in the guidelines and who may otherwise fall through the cracks. “A lack of a recommendation is not a recommendation against utilization,” Navar cautioned. “Everybody is welcome to overachieve in lowering LDL cholesterol if that is in line with what the patients want. We don’t have a clinical trial of LDL lowering in very low risk people. That does not mean that it’s not going to work, it just means that we have not been able to power a trial to do it.”

Add-On Therapy 

In a time when a high proportion of individuals live with cardiometabolic risk factors that predispose them to ASCVD, clinicians may need to use multiple tools in their toolkits to optimize prevention of adverse cardiovascular events. “We are not going to get there with statins alone,” Navar remarked. “Even ezetimibe, which is cheap and generic and easily prescribable, is still not used to the degree that it needs to be to get our patients to goal. I think the key is to educate our colleagues on combination therapy and work on messaging to patients that, if you are starting at an LDL cholesterol [level] that is 160 mg/dL and your goal is 55 mg/dL, it is going to take a couple of steps to get there. We have to bring patients back, follow up the LDL cholesterol, and plan for a series of titrations, quickly, not just once a year. The only way we are going to do that is by increasing the utilization of non-statins, starting with ezetimibe and then continuing on to the novel non-statins, [including] bempedoic acid and PCSK9 inhibitors. Without greater uptake of [those therapies], we are not going to get our patients to goal.”  

Prevention Should Start Early

A central focus of the updated recommendations for lipid management is identifying risk earlier in life and intervening sooner, whether through lifestyle changes or therapies. “I think one of the things that we have to do in prevention is start everything earlier,” Blankstein said. “We have a risk calculator that we can use earlier, at age 30. We need to at least start the discussion about risk and treatment sooner.” Some significant cardiovascular risk factors, such as lipoprotein(a), have a genetic component and should be identified early, the speaker added. 

Targets Beyond the LDL Cholesterol 

“We know that LDL cholesterol [measurement] becomes more inaccurate with lower on-treatment LDL-C levels,” Navar said. “We recommend using a validated equation to measure the LDL cholesterol levels. However, even at those very low LDL-C levels, you often get measurement errors. So, in those patients, it is really helpful to be following non-HDL cholesterol or apolipoprotein B levels, which are not calculated but directly measured and which don’t have the same measurement errors.” Goals for apolipoprotein B levels should generally match LDL-C targets, depending on risk level. The only exception is a recommendation for a target below 90 mg/dL for patients at low risk, whose LDL-C levels should be maintained below 100 mg/dL. 

Harmonized Guidelines  

In recent years, international recommendations for lipid management have moved toward closer alignment, emphasizing the same core principles for reducing cardiovascular risk. In an increasingly complex clinical landscape, consistent messaging can ensure that patients and providers have timely access to the most effective tools for preventing cardiovascular disease. “What we can do is message to patients and clinicians that there is now a consistency of the evidence,” said session moderator Pamela Morris, MD, associate professor at the Medical University of South Carolina, in Charleston, South Carolina. “This [approach] is less confusing to the patients and hopefully it will help with implementation, as they will feel like they can trust our recommendations and the science behind them.”