This commentary is based on Blumenthal RS, Morris PB, Gaudino M, et al. 2026 ACC/AHA/AACVPR/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of dyslipidemia: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2026;87(19):2624-2757. doi:10.1016/j.jacc.2025.11.016.¹

The 2026 ACC/AHA/Multisociety Guideline on the Management of Dyslipidemia replaces the 2018 cholesterol guideline, incorporating universal atherogenic lipoprotein screening, lipid assessment at earlier ages, lower risk category thresholds, and reaffirmation of South Asian ancestry as a risk enhancer. These changes directly improve risk assessment of South Asian patients, who are known to have higher Lp(a) burden and develop ASCVD at younger ages. The guideline incorporates apolipoprotein B (apo B), Lp(a), coronary artery calcium (CAC), and cardiovascular-kidney-metabolic (CKM) syndrome into risk-based decision-making.¹ Within this framework, ancestry is explicitly recognized as a clinically relevant risk-enhancing consideration. South Asian ancestry is identified as a demographic group at high risk and a risk enhancer, reflecting the increased prevalence of diabetes mellitus (DM) at lower BMI and waist-circumference thresholds and increased likelihood of progression along CKM stages.^1-3 South Asia has one of the highest burdens of chronic kidney disease globally, contributing to the overall risk of dyslipidemia and importance of risk stratification.⁴

The 2026 ACC/AHA/multisociety guideline also highlights meaningful variation in lipid-related risk across populations. Lp(a) levels are elevated in approximately 25% of South Asian individuals globally, with prospective studies identifying a median level that is second highest out of all ethnic groups. This elevation in Lp(a) level is associated with a higher population-attributable risk of myocardial infarction among South Asian individuals,^3,5 who also have a higher prevalence of small-dense LDL particles, making apo B useful for risk assessment. In this context, Lp(a) and apo B serve as important tools for risk refinement for South Asian patients in particular, helping clinicians identify residual atherogenic risk that may be underestimated by a standard lipid panel alone. Critically, the guideline frames ancestry as one component of a broader risk discussion: South Asian ancestry should raise clinical suspicion and prompt closer assessment of CKM features, metabolic syndrome, family history, Lp(a) level, apo B level, and CAC scoring when appropriate, but should not, by itself, mandate statin therapy. An overview of ancestry-related clinical guidance is provided in Table 1.

Table 1: South Asian Ancestry–Related Considerations and Suggested Clinical Actions

^a PREVENT-ASCVD is a trademark of the AHA
apo B = apolipoprotein B; DM = diabetes mellitus; MI = myocardial infarction; PREVENT-ASCVD = Predicting Risk of Cardiovascular Disease EVENTs–Atherosclerotic Cardiovascular Disease; TG = triglycerides.

Commentary

There are ample data that cardiovascular disease risk varies between ethnic and racial groups, but modern biomedical consensus holds that these differences are not due to genetically defined ancestry. The differences can rather be explained in part by social drivers of health, which impact a broad swath of factors that influence people's lives, including access to resources, culture, and environment. This impact is evidenced by studies showing that genetic diversity between South Asian populations approaches that difference between South Asian groups and other continental groups (Europe and East Asia).³ This evidence begs the question as to whether race or ethnicity should be considered at all when determining a patient's individual risk of ASCVD, and how they should inform clinical guidance in the pursuit of preventing adverse health outcomes. The 2026 ACC/AHA/multisociety guideline recommends individualized risk assessment with the PREVENT (Predicting Risk of Cardiovascular Disease EVENTs [AHA]) equation alongside testing for Lp(a) and apo B and considering comorbid conditions such as DM and CKM.¹ Yet there is an underlying enhanced risk that is not captured by any of these measurable factors, prompting the recommendation that South Asian ancestry be used as a proxy.

Perhaps this increased risk is a result of stressors related to immigration and discrimination, language discordance, economic instability, and acculturation challenges.⁶ However, those stressors would not explain why South Asian individuals born in the United States are also at higher risk,^2-3 nor why their risk remains higher than that for other immigrants who have experienced similar struggles. Dietary patterns offer a mixed picture, with an interplay of traditional vegetarian diets influenced by Western consumption patterns that are not conclusively better or worse at explaining excess risk compared with white counterparts.^2-3 Exercise habits are clearer, with South Asian individuals having lower odds of meeting aerobic and muscle-strengthening recommendations. Ultimately, a combination of all these factors and some genetic association may explain why South Asian individuals have increased rates of risk factors, which include comorbid conditions such as hypertension and DM, elevated plasma insulin levels, altered plasma lipid profiles (Lp[a] and apo B), increased visceral fat storage, and elevated inflammatory markers.^2-3

Clinicians should thus take a holistic approach to evaluating South Asian patients with the 2026 ACC/AHA/multisociety guideline. The PREVENT-ASCVD (Predicting Risk of Cardiovascular Disease EVENTs–Atherosclerotic Cardiovascular Disease [AHA]) calculator provides a baseline assessment, improved from prior scores in representativeness but still not fully capturing risk. Introducing Lp(a) into the equation may be useful for South Asian patients given that approximately one-quarter of the population has elevated levels.⁷ Ancestry can thus prompt a heightened level of scrutiny for risk factors such as family ASCVD history, gestational diabetes, and earlier Lp(a) level measurement, particularly in patients who are younger and have normal-range BMIs.8 CAC scoring is a powerful tool recommended by the new guideline to guide treatment for subclinical disease, and it is race neutral.¹ The decision to obtain a CAC score can be made, factoring in South Asian ancestry afterward using the PREVENT calculation. However, a CAC score of 0 does not guarantee reassurance due to higher proportions of noncalcified plaque in South Asian individuals, especially in those who are younger.^9-10 If additional risk factors are present such as elevated Lp(a) levels and strong family history, coronary CT angiography should be considered to identify subclinical disease.¹⁰ A flowsheet for assessing risk is provided in Figure 1.

Figure 1: Ancestry-Informed Risk Assessment in Groups at High Risk

^a PREVENT-ASCVD is a trademark of the AHA
apo B = apolipoprotein B; CAC = coronary artery calcium; CKM = cardiovascular-kidney-metabolic; DM = diabetes mellitus; HLD = hyperlipidemia; HTN = hypertension; MI = myocardial infarction; PREVENT-ASCVD = Predicting Risk of Cardiovascular Disease EVENTs–Atherosclerotic Cardiovascular Disease; TG = triglycerides.

Community health outreach and patient education can also play an important role in empowering individuals to take charge of their own health rather than relying solely on clinicians. Many South Asian individuals know about their enhanced risk from experiences with family members but may not have a clear understanding of how to be proactive about their own health. Educating them about PREVENT score calculation and atherogenic lipoprotein burden assessment can be a key step in heightening awareness and starting conversations with their doctors about updated tools to assess increased risk, particularly for primary care providers who serve at the front line for long-term disease prevention and management. At Johns Hopkins, the community health fair intervention provides an outlet to do this work by bringing patients into the fold and giving them the tools to understand their unique risks in a culturally tailored way. There are plans to add education about the 2026 ACC/AHA/multisociety guideline to the health education stations. As with all medicine, there is considerable lag in the widespread adoption of clinical practice recommendations. Addressing South Asian health disparities from both the patient and clinician sides speeds up recognition of risk and delivers equitable care for a vulnerable population.

References

1. Blumenthal RS, Morris PB, Gaudino M, et al. 2026 ACC/AHA/AACVPR/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of dyslipidemia: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2026;87(19):2624-2757. doi:10.1016/j.jacc.2025.11.016
2. Rohatgi A, Anand SS, Gadgil M, et al. South Asians and cardiometabolic health: a framework for comprehensive care for the individual, community, and population - an American Society for Preventive Cardiology clinical practice statement. Am J Prev Cardiol. 2025;22:101000. Published 2025 Apr 22. doi:10.1016/j.ajpc.2025.101000
3. Agarwala A, Satish P, Rifai MA, et al. Identification and management of atherosclerotic cardiovascular disease risk in South Asian populations in the U.S. JACC Adv. 2023;2(2):100258. doi:10.1016/j.jacadv.2023.100258
4. GBD 2023 Chronic Kidney Disease Collaborators. Global, regional, and national burden of chronic kidney disease in adults, 1990-2023, and its attributable risk factors: a systematic analysis for the Global Burden of Disease Study 2023. Lancet. 2025;406(10518):2461-2482. doi:10.1016/S0140-6736(25)01853-7
5. Patel AP, Wang M, Pirruccello JP, et al. Lp (a)(lipoprotein[a]) concentrations and incident atherosclerotic cardiovascular disease: new insights from a large national biobank. Arterioscler Thromb Vasc Biol. 2021;41(1):465-474. doi:10.1161/ATVBAHA.120.315291
6. Ahmed N, De Silva D, Kanaya AM, Kandula NR. Psychological symptoms as mediators in the association between discrimination and health among South Asian Americans. J Asian Health. 2022;2(1):e202209.
7. Patel J, Bhatia HS, Spitz JA. E pluribus unum-: understanding our diversity and disparities in Lp(a) screening. JACC Adv. 2024;3(6):100939. Published 2024 May 1. doi:10.1016/j.jacadv.2024.100939
8. Kanaya AM, Shah NS, Prabhakaran D, Virani SS. Improving primary prevention in South Asians: a regional perspective for the 2026 dyslipidemia guidelines. J Am Coll Cardiol. 2026;87(19):2603-2605. doi:10.1016/j.jacc.2026.03.065
9. Jain V, Rifai MA, Kanaya AM, et al. Association of cardiovascular health with subclinical coronary atherosclerosis progression among five racial and ethnic groups: the MASALA and MESA studies. Atherosclerosis. 2024;392:117522. doi:10.1016/j.atherosclerosis.2024.117522
10. Kalra DK, Vedamurthy D, Hosadurg N, et al. South Asian cardiovascular risk: role of coronary artery calcium scoring and computed tomography angiography. JACC Asia. 2026;6(8 Pt 2):1657-1677. doi:10.1016/j.jacasi.2026.07.007