For the first time since 2018, the American College of Cardiology and American Heart Association clinical guidelines for screening and managing blood cholesterol levels have been updated and jointly published. Journal of the American College of Cardiology and circulation. The new guidelines will be discussed at the American College of Cardiology’s 75th Annual Scientific Sessions on March 28 in New Orleans.
The release of the guidelines also came a week before a paper titled “The ABCs of cardiovascular disease prevention: Telling what we know in 2026” was published in the journal. American Journal of Preventive Cardiology.
The new guidelines focus on recommendations to reduce elevated levels of low-density lipoprotein (LDL) cholesterol (often referred to as bad cholesterol) and other types of fats circulating in the bloodstream, such as lipoprotein(a) and Lp(a). It also highlights the importance of early screening, particularly for patients with a family history of heart disease, and more individualized risk estimation, such as for those with underlying conditions, to support shared decision-making between clinicians and patients.
We know that lower LDL cholesterol levels are better when it comes to reducing your risk of heart attack, stroke, and congestive heart failure. We also know that lowering elevated lipids and blood pressure in young adults supports optimal heart and vascular health throughout life. ”
Roger S. Blumenthal, MD, Chair of the Guideline Development Committee and Director of the Johns Hopkins Center for Cardiovascular Disease Prevention
The latest guidelines come at a time when research shows that one in four U.S. adults has elevated LDL cholesterol (LDL-C), a risk factor for atherosclerosis (narrowing or hardening of the arteries). Excessive accumulation of certain lipids can promote the growth and development of plaque within the arteries. The presence of moderate atherosclerotic plaques in the arteries of the heart can block blood flow. Other factors, such as age and other cardiovascular risks, can make plaques more likely to dislodge, potentially causing a heart attack or stroke or requiring emergency intervention to restore circulation.
Blumenthal emphasizes that the basic principles known to support a heart-healthy lifestyle and keep cholesterol levels within normal limits remain the same. These include eating a heart-healthy diet, getting regular vigorous physical activity, avoiding tobacco, getting enough sleep, and maintaining a healthy weight. He emphasizes the fact that approximately 80% to 90% of cardiovascular disease is at least partially due to modifiable risk factors, and that a focus on lifestyle interventions should therefore be the first, or foundational, approach.
The new cholesterol guideline changes call for earlier screening and risk assessment of lifelong risks, such as family history of atherosclerosis, underlying conditions such as rheumatoid arthritis, and the presence of certain pregnancy complications such as early menopause and pre-eclampsia and gestational diabetes, to help inform treatment decisions.
For example, new guidelines recommend that people with a history of familial hypercholesterolemia or who are genetically gifted with very high LDL-C levels get tested early in life, starting in childhood around age 9 (or earlier). The guidelines also recommend one-time screening for Lp(a) levels, which are often associated with genetic risk, with levels of 125 nanomoles per liter increasing the risk of heart disease by about 40% and levels of 250 nanomoles per liter potentially doubling the risk.
Another update includes the use of new risk calculators for 10-year and 30-year risk estimates for heart attack and stroke. Previously, pooled cohort equations were used to predict 10-year heart disease risk for people over 40 years of age. That calculator included baseline risks such as age, cholesterol levels, and blood pressure. A newer calculator called Predicting Risk of Cardiovascular Disease Events (PREVENT) incorporates additional data, including indicators of blood sugar levels and kidney health, and is recommended for use starting at age 30 to estimate these risks. PREVENT scores are based on data collected from 6.6 million people. Previous calculations were based on 26,000 people.
“Shifting the paradigm toward aggressive prevention strategies early in life could meaningfully change the trajectory of cardiovascular disease and improve people’s health outcomes decades later,” said Seth Martin, MD, a cardiologist, member of the guideline development committee, and director of the Progressive Dyslipidemia Program and Digital Health Lab at the Johns Hopkins Siccarone Center for Cardiovascular Disease Prevention.
To further support individualized risk assessment, the guideline also provides recommendations to help clinicians account for atherosclerosis “risk enhancers.”
For example, if the risk of atherosclerosis is borderline to moderate, 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). Elevated Lp(a) may also be considered, as well as other factors such as family history of early cardiovascular disease or high-risk ancestry. In addition to those that increase risk, the updated guidelines provide multiple recommendations for the use of coronary artery calcium scans, which detect calcium deposits in arteries that represent plaque, to aid in individualized treatment decisions.
The updated guidelines include recommendations for treatment decisions for pregnant or breastfeeding women, adults over 75 years of age, people with underlying medical conditions such as diabetes, end-stage chronic kidney disease, and HIV infection, and people being treated for cancer.
The new guidelines provide details on statin therapy, along with updated information on other lipid-lowering treatments such as ezetimibe, bempedoic acid, and injectable PCSK9 monoclonal antibody therapy. The latter is recommended for people who may not respond well to statin therapy or who need a combination of treatments to lower their LDL-C levels.
Optimal LDL-C levels for people without cardiovascular disease are thought to be less than 100 mg/dL. Current guidelines recommend that people at moderate risk lower their LDL-C levels to below 70 mg/dL. People at high risk should have LDL-C levels below 55 mg/dL. In addition to targeting LDL-C, the guidelines also provide recommendations for non-HDL-C and apolipoprotein B, a cholesterol-bound molecule.
In an editorial accompanying the new guidelines, Blumenthal and vice chair of the 2026 ACC/AHA/Multisocial Dyslipidemia Guidelines predicted that future guidelines will also likely recommend aiming to lower LDL-C levels to less than 55 mg/dL for people with at least moderate atherosclerosis. The 2026 guidelines were developed before the results of the clinical trial VESALIUS-CV were published in academic journals. New England Medical Journal. In that trial, researchers discovered the benefits of targeting these ranges (by using a combination of lipid-lowering therapies).
The 2026 Guidelines for the Management of Dyslipidemia is a report of the American College of Cardiology and American Heart Association Joint Committee on Clinical Practice Guidelines. It was developed in collaboration with and with approval from the American College of Cardiovascular and Pulmonary Rehabilitation, the Black Association of Cardiologists, the American College of Preventive Medicine, the American Diabetes Association, the American Geriatrics Society, the American Pharmacists Association, the American College of Preventive Cardiology, the National Lipid Association, and the Preventive Cardiovascular Nurses Association.
Blumenthal is chairman of the guidelines development committee. Martin is a member of the committee. Other authors on the guideline development committee include Morris PB, Gaudino M., Johnson HM, Anderson TS, Bittner VA, Blankstein R., Brewer LC, Cho L., de Ferranti SD, Gianos E., Gluckman TJ, Gradney K., Isiadinso I., Lloyd-Jones DM, Marrs JC, McLain KH, Mehta LS, Mora S., Mulugeta WM, Natarajan P., Navarre AM, Olinger CE, Polonsky TS, Reynolds HR, Saseen JJ, Shapiro MD, Sofa DE, Tynes SA, Villabaso CD, Virani SS, Wilkins JT.
Martin disclosed previous research discussions with Amgen, Arrowhead Pharmaceuticals, AstraZeneca, Kaneka Pharma, Merck, New Amsterdam Pharma, Novartis, and Sanofi, as well as an ownership interest in Cory Health. Blumenthal and the majority of the writing committee had no ties to the industry.
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Reference magazines:
Blumenthal, R.S. Others. (2026). 2026 ACC/AHA/AACVPR/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guidelines for the Management of Dyslipidemia. jack. DOI: 10.1016/j.jacc.2025.11.016. https://www.jacc.org/doi/10.1016/j.jacc.2025.11.016
