In brief
The 2026 ACC/AHA multisociety guideline on the management of dyslipidemia replaces the 2018 cholesterol guideline. The central message is not that everyone needs the same LDL-C level: risk assessment, lifelong exposure to atherogenic particles and treatment goals should be tailored to the person.
The guide below explains eight practical changes, who they apply to and where the exceptions matter. For the exact recommendations, refer to the AHA guideline summary and ACC release.
2018 vs 2026: the practical shift
| Topic | Earlier 2018 approach | 2026 approach |
|---|---|---|
| Primary-prevention risk | Pooled Cohort Equations generally guided discussion. | Use PREVENT-ASCVD in the population for whom it is recommended. |
| LDL-C treatment | Percent LDL reduction and selected treatment thresholds were prominent. | Percent reduction remains important; risk-specific LDL-C and non-HDL-C goals also guide treatment. |
| Lp(a) | Considered primarily in selected risk discussions. | Measure at least once in adulthood to identify inherited risk. |
| Beyond LDL-C | Additional markers used selectively. | Stronger guidance on selective ApoB measurement and selective CAC risk refinement. |
This is a simplified comparison, not a substitute for the complete guideline algorithms. Particular situations such as established ASCVD, familial hypercholesterolemia or LDL-C at least 190 mg/dL need their own pathway.
1. PREVENT replaces the old risk equations in many adults
For adults aged 30–79 without known ASCVD or subclinical atherosclerosis and with LDL-C 70–189 mg/dL, the 2026 guideline recommends PREVENT-ASCVD to estimate the risk of a first heart attack or stroke. The tool is not intended to overrule existing coronary plaque or other conditions that already warrant treatment.
| 10-year PREVENT-ASCVD risk | Interpretation | Clinical implication |
|---|---|---|
| Less than 3% | Low | Healthy habits; individual exceptions may justify treatment. |
| 3% to less than 5% | Borderline | Lipid-lowering medication is reasonable after discussion. |
| 5% to less than 10% | Intermediate | Lipid-lowering medication is recommended alongside lifestyle changes. |
| 10% or higher | High | Intensive risk reduction and appropriate LDL-lowering therapy. |
Clinicians then personalize the estimate with risk enhancers and may reclassify selected patients using CAC. Try our free PREVENT score calculator, read the PREVENT explainer, or use the official AHA calculator.
2. LDL-C treatment goals are back
LDL-C percentage reduction still matters, but the guideline also specifies treatment goals according to clinical risk. These are clinical treatment goals, not universal screening cutoffs.
| Clinical group | Illustrative LDL-C goal |
|---|---|
| Primary prevention, borderline or intermediate PREVENT risk | Below 100 mg/dL |
| Primary prevention, high PREVENT risk | Below 70 mg/dL |
| Established ASCVD, very high risk | Below 55 mg/dL |
Established ASCVD without very-high-risk features, severe hypercholesterolemia and other conditions have separate recommendations. Do not infer your personal target from this short table alone. Read our LDL-C and ApoB targets guide.
3. Lp(a) should be measured at least once
Lipoprotein(a), or Lp(a), is largely genetically determined. The 2026 guideline recommends at least one measurement to identify elevated inherited risk. An Lp(a) of 125 nmol/L (50 mg/dL) or higher is a risk-enhancing factor; higher levels can indicate greater risk.
Laboratories may report mg/dL or nmol/L. The numbers cannot be converted using a universal fixed multiplier because Lp(a) particles vary in size. Elevated Lp(a) calls for more attention to LDL-C and other risk factors, not the assumption that a diet can reliably lower Lp(a) itself. Read our in-depth Lp(a) guide.
4. ApoB may reveal risk that LDL-C misses
ApoB reflects the number of atherogenic lipoprotein particles more directly than LDL-C concentration does. Selective ApoB testing can be especially useful when triglycerides are above 200 mg/dL, diabetes is present or achieved LDL-C is already below 70 mg/dL.
It is an additional tool, not a mandate to order every possible biomarker for every patient. A clinician can use ApoB to reassess residual risk and the need for further LDL-lowering treatment. See LDL particle number vs ApoB.
5. CAC can change an uncertain treatment decision
A coronary artery calcium (CAC) scan can improve risk classification in selected adults when the need for preventive medication is uncertain. The guideline highlights CAC use in men aged at least 40 and women aged at least 45 in appropriate scenarios.
A CAC score of zero does not exclude noncalcified plaque or erase risk from major factors such as diabetes, smoking, markedly high LDL-C or elevated Lp(a). A positive score documents calcified coronary plaque and changes the prevention discussion. Our CAC score guide explains interpretation and limitations.
6. Prevention may start earlier
Lifetime exposure to elevated LDL-C matters. The guideline emphasizes healthy habits from youth and earlier assessment when there is familial hypercholesterolemia, LDL-C of at least 160 mg/dL in young adulthood or a strong family history of premature cardiovascular disease.
This does not mean every younger adult with elevated cholesterol should automatically start a drug. It means that lifelong risk and inherited conditions should not be ignored simply because 10-year risk appears low.
7. Some conditions call for treatment beyond the calculator
For many adults aged 40–75 with diabetes, stage 3 or 4 chronic kidney disease or HIV, LDL-lowering therapy is recommended for primary prevention regardless of the calculated PREVENT risk estimate. Special approaches also apply to those with established ASCVD and severe primary hypercholesterolemia.
After age 75, individualized discussion of potential benefits, risks, health status and preferences remains important. See statins after age 75.
8. Non-HDL-C and other lipids still matter
The guideline includes non-HDL-C treatment goals and emphasizes assessing triglyceride-rich particles in the right context. People with persistent high triglycerides may need additional evaluation, especially when the triglyceride level is high enough to raise pancreatitis risk.
LDL-C lowering with therapies shown to reduce cardiovascular events remains central. A favorable change in a lab marker is not automatically proof that every supplement or newly approved medicine prevents heart attacks.
New randomized evidence after the guideline cutoff: Ez-PAVE (March 2026)
Clinical evidence · Absolute event rates
3,048 patients with established ASCVD; intensive versus conventional LDL-C target · Bars share a 0–12% scale.
Open-label trial in South Korea. Median achieved LDL-C was 56 versus 66 mg/dL; endpoints included revascularization and unstable angina hospitalizations. NEJM original randomized trial ↗
The guidelines used evidence through late 2024, so Ez-PAVE did not determine the original recommendations. Published in New England Journal of Medicine on 28 March 2026, the South Korean open-label trial randomized 3,048 people with established ASCVD to an LDL-C goal below 55 mg/dL or below 70 mg/dL. Over three years, the composite cardiovascular endpoint occurred in 6.6% versus 9.7% (HR 0.67; 95% CI 0.52–0.86). Median achieved LDL-C was 56 versus 66 mg/dL.
This supports more intensive targets in appropriate secondary-prevention patients, not automatic extrapolation to everyone with elevated cholesterol. The open-label design, combined endpoint and single-country population matter. Read the Ez-PAVE primary trial and our LDL/ApoB target guide.
Five questions to take to your next appointment
- Which risk category applies to me, and does PREVENT fit my situation?
- What are my LDL-C and non-HDL-C goals, and why?
- Have I had an Lp(a) measurement, and would ApoB add useful information?
- Would CAC scoring help settle a treatment decision in my case?
- If my LDL-C remains above goal, which therapy has the strongest outcomes evidence for me?
For practical lifestyle planning, see our evidence-based diet hub; a dietary program should complement, not replace, indicated medical treatment.
Primary sources and further reading
- American Heart Association. Top Things to Know: 2026 Guideline on the Management of Dyslipidemia. Updated 13 March 2026.
- American College of Cardiology. ACC/AHA Issue Updated Guideline for Managing Lipids, Cholesterol. 13 March 2026.
- American Heart Association. PREVENT-ASCVD online calculator.
- Blumenthal RS and colleagues. 2026 ACC/AHA multisociety dyslipidemia guideline. Circulation, 2026.
Editorial note: Research evidence checked 30 October 2026.