Leading medical organizations on Friday recommended major changes to cardiovascular disease prevention, saying people as young as 40 to 30 should consider statins and other measures to manage cholesterol.
Beyond just LDL (“bad”) cholesterol and statins, the latest recommendations take a more comprehensive approach to how and when to prevent and treat cardiovascular disease caused by hardening and narrowing of the arteries.
In people without heart disease, if LDL (“bad”) cholesterol levels reach 160 mg/dL or higher starting in young adulthood at age 30, behavioral changes or additional medications are encouraged. That approach starts with a healthier lifestyle and can progress to adding statins or other drugs if there is a strong family history of early heart disease or if a risk assessment shows a person has a high chance of developing cardiovascular disease over a 30-year period. If diet and exercise do not lower lipids sufficiently, imaging calcium in the coronary arteries may be an option to assess some people’s risk of heart attack or stroke before deciding on medications.
“These guidelines represent an important shift in identifying high-risk individuals earlier and treating them more effectively,” Greg Fonarow, a cardiologist and professor of cardiovascular medicine and science at UCLA, told STAT in an email. He was not involved in the drafting of the guidelines. “It is deeply concerning that cardiovascular events occur every year that could have been prevented if risks had been identified and treated early. These new guidelines provide a clearer, more modern roadmap to help reduce this burden.”
The new guidelines from the American College of Cardiology, the American Heart Association and nine other medical organizations are based on a risk calculator released in November 2024 that has been hailed as more reliable than previous formulas derived from less comprehensive evidence.
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The new calculator has been causing concern over the past 16 months. It turns out that far fewer people are eligible to receive statins when used in conjunction with existing treatment standards. Many people were already not taking their prescribed statins, so a 40% drop in the number of people covered was a cause for concern as a failure of prevention.
The new 2026 guidelines adopt the new PREVENT equation (which stands for Predicting Risk of Cardiovascular Disease Events) and also adjust the threshold for taking steps to remove fatty plaques in arteries. The optimal level of LDL has been lowered, and the risk threshold for prescribing better diet and physical activity, drugs, or both has also been adjusted downward.
Timothy Anderson, a primary care physician and assistant professor of medicine at the University of Pittsburgh Medical Center, is one of the researchers who expressed concerns about matching PREVENT to risk thresholds. He, who is also a member of the 2026 guideline development committee, praised PREVENT’s equation as a well-validated risk estimation tool with cutting-edge accuracy.
“The whole rationale is this idea of trying to balance the potential benefits and potential risks of lipid-lowering therapies like statins,” he told STAT. “The real focus of this guideline is to identify and treat high cholesterol early, based on the hypothesis that long-term exposure to high cholesterol may have greater risks than short-term exposure.”
early recognition
Earlier intervention means looking at 10-year risk estimates as well as 30-year projections.
The new PREVENT equation classifies the 10-year cardiovascular disease risk from plaque-covered arteries as low (<3%), borderline (3% to 5%), intermediate (5% to 10%), and high (≥10%). These risk categories form the basis of treatment decisions, from initiating statin therapy to determining the intensity of lipid lowering. A combination of other factors, such as family history, inflammatory diseases, diabetes, kidney disease, cancer, HIV, and certain reproductive diseases, affect how risk is calculated.
Treatment at much lower LDL levels is now recommended, depending on your current health status. To prevent your first heart attack or stroke, your LDL should be less than 100 mg/dL for borderline or intermediate-risk people and less than 70 mg/dL for high-risk people. However, in people who already have fat buildup in their blood vessels and are considered to be at very high risk for heart attack, stroke, and peripheral artery disease, the LDL goal drops below 55 mg/dL.
Roger Blumenthal, chairman of the guideline committee and director of the Johns Hopkins Siccarone Heart Disease Prevention Center, compared lipid-lowering drugs to drugs that lower blood pressure. The longer both are under control, the stronger the protection against future heart attack and stroke risk. This suggests the need to consider 10-year risk estimates as early as age 30.
“The PREVENT score gives you a well-founded guess, but keep in mind that this number is quite low when you consider that a moderate risk is a 5% to 10% risk over 10 years,” he told STAT. “Some patients have already said, ‘Well, Dr. Blumenthal, there’s a 1 in 20 chance that I’ll have a cardiovascular event.’ That’s really true. But I tell them that if there are other factors that support early treatment, that may prompt us to manage more aggressively.”
Other factors affecting risk
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In addition to family history, other factors that may increase your risk include being overweight or obese, diabetes, chronic kidney disease, and chronic inflammatory conditions such as lupus or rheumatoid arthritis. Having South Asian or Filipino ancestry also means you have a higher risk of developing atherosclerosis.
Women tend to develop atherosclerosis about 10 years later than men, but that delay disappears if they experience early menopause, preeclampsia, gestational diabetes, or high blood pressure during pregnancy. “If you have any of the reproductive risk markers that indicate increased cardiovascular risk, I think more clinicians and patients will be more proactive about making lifestyle changes and, if necessary, using cholesterol-lowering drugs,” Blumenthal said.
In recent years, blood markers other than cholesterol have received more attention. Lipoprotein(a), apolipoprotein B (ApoB), and high-sensitivity C-reactive protein are thought to be important in establishing someone’s risk. Lp(a) is genetically formed, shared by about 1 in 5 Americans, and should be measured once in a lifetime, the guidelines say. Levels above 50 mg/dL increase your long-term risk of heart attack or stroke by about 40%. Although lifestyle changes do not change Lp(a) levels, the combination of high Lp(a) and high LDL should signal a conversation about lowering LDL. Blumenthal said Lp(a) can be a tiebreaker for patients in the midst of treatment.
In people with cardiovascular, renal, or metabolic syndrome, type 2 diabetes, high triglycerides, or known cardiovascular disease who are meeting their cholesterol goals, ApoB may be a more accurate risk marker for future cardiovascular disease than LDL cholesterol, the guidelines state.
Role of statins
Throughout the 123-page guidelines, emphasis is not just on statins and LDL cholesterol. While the authors recognize that not everyone who could benefit is taking statins, they still place statins in early treatment.
The mainstay of cardiovascular disease prevention has long sold for about $40 a year. Introduced in the 1980s, they have been compared to today’s obesity drugs because of their impact in preventing heart attacks, strokes, and peripheral artery disease. One drawback is that there is a mismatch between who benefits and who actually takes the drug.
There are side effects and fear of them. Some people experience muscle aches, while others have high blood sugar levels that can cause them to develop type 2 diabetes. Studies have estimated that the absolute risk increase ranges from 0.1% to 0.5%. Blumenthal said more than 95% of patients have no problems taking the drug.
Jeremy Sussman, a primary care physician at the VA Ann Arbor Healthcare System who was not involved in writing the guidelines, believes statins are invaluable drugs, but worries about patients who may find taking them too aggressive. Although you are less likely to develop muscle pain or diabetes, your chances of having a heart attack or stroke also seem small at first and only gradually decrease over time.
“It’s worth it for many of us because a heart attack can be a terrible thing,” he said in an email. “But it’s worth recognizing that we are encouraging high doses of statins that will only provide benefits for a very long time.”
Sussman also said it was disappointing that primary care physicians were not represented in the medical societies that wrote the guidelines. He also said the guidelines are not sufficiently patient-centered, which is important given that so many at-risk people stop taking cholesterol-lowering drugs within two years of starting them.
“The most difficult question in treating dyslipidemia is rarely whether or when a patient’s risk and cholesterol levels are high enough. We understand patient values and help patients overcome their drug aversion with the goal of preventing heart attacks 20 years from now. “We’re trying to understand how doctors and patients can decide whether they should start taking the drug today,” he said, adding, “While these issues are recognized, the guidelines do not provide much guidance on these related issues.”
Not just statins
Statins are not the only drugs that control cholesterol. It may also be used in combination with other more powerful drugs if lipids remain high. These include PCSK9 inhibitors, which are drugs that reduce LDL cholesterol by blocking proteins.
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In an editorial published with the JACC and Circulation guidelines, Blumenthal detailed the trials of PSCK9 inhibitors. Data on the drug’s use in humans before the first heart attack was presented at the AHA’s Scientific Sessions in November 2025, too late for guidelines, but a harbinger of research to come. The guidelines are updated annually to provide resources to physicians.
“With short-term follow-up of about two to three years, PCSK9 inhibitors reduced the relative risk by about 15 to 20 percent on top of statin therapy,” Blumenthal said, exaggerating. “Statins are much more economically viable than PCSK9 inhibitors, and insurance companies will likely be more willing to pay for a generic statin than a drug that can cost patients $5,000 a year.”
In addition to blood tests for lp(a), apo(b), and the better known fat storage triglycerides, there is a test called a coronary artery calcium scan that can help determine whether to take a statin. If someone’s risk is uncertain, a scan may reveal calcium or plaque buildup in artery walls. This test is recommended for men over 40 and women over 45 who have a borderline or moderate 10-year risk of heart attack or stroke. The 2018 guidelines recommended them only for people at moderate risk.
In Blumenthal’s view, there are now many ways to identify people at high risk. It’s not the challenge it once was.
“Really the hardest part is motivating people to improve their lifestyle habits,” Blumenthal says. “But it’s often difficult to get people to understand that there’s a lot of great data that the longer you keep your blood pressure low, the better. If we can motivate people to keep trying to make lifestyle changes early on, we’ll need less medication and we’ll have less of a need to deal with these acute cardiac events that unfortunately plague so many people in the United States and around the world.”
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