Prioritizing Health | Lower Sooner: How the 2026 Dyslipidemia Guideline Changes Practice
Earlier intervention and lower goals for LDL-C are key recommendations in the ACC/AHA Dyslipidemia Guideline,1,2 published in March – recognizing the risks of prolonged exposure to dyslipidemia leading to atherosclerotic cardiovascular disease (ASCVD). It offers a comprehensive "one-stop shop" for addressing the evaluation, management and monitoring of individuals with dyslipidemias, including high blood cholesterol, hypertriglyceridemia, and elevated lipoprotein(a) (Lp[a]). Here's an overview to put this into practice now.
The "CPR" Model: Calculate, Personalize, Reclassify
The guideline introduces the "CPR" model for approaching a patient with cardiovascular risk factors. First, calculate the 10- and 30-year risk with the new PREVENT score. Next, personalize risk by considering risk enhancers not included in the PREVENT calculator, such as family history of premature ASCVD, reproductive risk markers, chronic inflammatory disease, or high levels of biomarkers like Lp(a) or high-sensitivity CRP (hsCRP). Lastly, reclassify the patient and their treatment and potentially reassess based on their coronary artery calcium (CAC) score. This model helps guide patients and their care team to the best combination of lifestyle modification and lipid-lowering therapy (LLT) for their current constellation of risk factors.
Absolute LDL-C Treatment Goals
In patients with a high (≥10%) 10-year PREVENT ASCVD risk score, LLT should be used to achieve goals of LDL-C <70 mg/dL and non–HDL-C <100 mg/dL. In adults with borderline (3-5%) or intermediate (5-10%) risk, LLT should be used to achieve LDL-C <100 mg/dL and non–HDL-C <130 mg/dL. These guidelines reintroduce specific value-based goals and replace the former, percent-reduction-based goals.
Lp(a): An Emerging Risk Stratifier
The 2026 guideline recommends Lp(a) measurement at least once in every adult's lifetime, as it has emerged as a prevalent, consistent and useful marker of ASCVD risk.3 This is the first time the ACC/AHA guideline has made universal screening and genetic cascade screening recommendations regarding Lp(a). Values of Lp(a) >125 nmol/L and >250 nmol/L are associated with 1.4-fold and ≥2-fold increased ASCVD risk, respectively.
Because Lp(a) is genetically determined and relatively stable across a lifespan, one early measurement is sufficient and helpful to guide early preventive therapies and lifestyle changes. Adults with elevated Lp(a) levels, regardless of their LDL-C level, should be offered early options for reducing cardiovascular risk.
Apolipoprotein B
While LDL-C remains the mainstay of cholesterol screening and target, the guideline recognizes that the measurement of apolipoprotein B (apoB) can be useful in patients with ASCVD or at high-risk. ApoB more accurately reflects ASCVD risk, therefore intensification of LLT can be considered for patients with elevated apo B, even if LDL-C or non–HDL-C are at goal. The use of apoB measurement may be useful in primary prevention patients to help refine decisions regarding initiation of LLT.
CAC Scoring
The use of coronary artery calcium scoring was upgraded from a level 2a to a level 1 recommendation for risk stratification beyond PREVENT scores. CAC scoring quantifies the amount of calcified coronary plaque visible on noncontrast-gated cardiac CT, ranging from absent coronary plaques (0 AU) to extensive (≥1000 AU). In patients with borderline indications for LLT or for whom the intensity of treatment needed is unclear, CAC scores can help refine the choice of intervention. A score of zero can be used to defer statin therapy in a low- or intermediate-risk patient with no other cardiovascular comorbidities.
Primary Prevention in Chronic Disease
The guideline now includes adults aged 40-75 with chronic kidney disease (CKD) ≥stage 3 or with HIV in the special patient populations for whom physicians should initiate LLT as primary prevention regardless of LDL-C or PREVENT score. This emphasizes that a diagnosis of HIV or CKD is an independent risk factor for an ASCVD event.
Reproductive Risk Markers
The 2026 guideline has included reproductive risk markers as important factors to support a more personalized ASCVD risk assessment. Initial evaluation should identify whether any of the following reproductive risk markers are present: adverse pregnancy outcomes (preeclampsia, gestational hypertension, gestational diabetes or preterm delivery), premature or early menopause (age <40 and <45 years, respectively) or polycystic ovarian syndrome [PCOS]). These reproductive risk markers are associated with an increased risk of future ASCVD events and adverse cardiac outcomes. History of adverse pregnancy outcomes should guide discussions regarding prevention and initiation of LLT with patients.
Putting It Together
The 2026 ACC/AHA dyslipidemia emphasize earlier intervention and more aggressive LDL targets to reduce lifetime ASCVD risk. A new pragmatic "CPR" approach individualizes ASCVD risk assessment. Primary prevention populations who should be initiated on or considered for LLT are expanded, using the PREVENT score and risk-enhancing factors such as reproductive risk markers. Universal once in a lifetime screening for LP(a) along with expanded use of apo B are recommended for risk stratification beyond LDL-C.
Key Points For Clinicians
- It's never too early to discuss cardiovascular risk. Use the new PREVENT score to calculate a patient's 10- and 30-year risk of ASCVD.
- Achieving target absolute LDL-C and non–HDL-C levels is essential.
- All adults should have their Lp(a) level checked once in their lifetime.
- Adults with CKD stage 3 and HIV meet criteria for LLT regardless of their PREVENT score.
- Screening for reproductive risk enhancing factors should be incorporated into routine risk assessment.
Key Point For Patients
- Reduce your lifetime risk of cardiovascular disease by meeting your individual LDL-C target earlier in life.
- LDL-C and non–HDL-C targets are based on your risk factors and are your tailored goal.
- Ask your doctor to check your Lp(a) level, which can increase your risk of heart disease. This should be checked once during your lifetime.
- If you have CKD stage 3 or HIV, talk to your doctor to be sure you are on medications that will lower cholesterol, which lowers your chances of heart disease.
- Make sure your cardiologist knows if you have a history of an adverse pregnancy outcome like preeclampsia, early menopause or PCOS, which are associated with future heart disease.
This article was authored by Nicole Dagen, BS; Colleen McCarthy, MD; and Verity Ramirez, MD, FACC, all at the Brown University Warren Alpert School of Medicine in Providence, RI. Interested in prevention? Learn about and join ACC's Prevention of Cardiovascular Disease Member Section.
References
- Blumenthal R, Morris P, Gaudino M, et al. 2026 ACC/AHA Guideline on the Management of dyslipidemia. JACC. 2026;87(19):2624-2757.
- Wiggins B, Barac A, Benziger C, et al. 2026 Dyslipidemia Guideline-at-a-Glance. JACC. 2026;87(19):2617-2623.
- Nordestgaard BG, Langsted A. Lipoprotein(a) and cardiovascular disease. Lancet. 2024;28;404(10459):1255-1264.
Clinical Topics: Dyslipidemia, Lipid Metabolism, Nonstatins
Keywords: Cardiology Magazine, ACC Publications, CM-Jul-Aug-2026, Dyslipidemia, Cholesterol, Guidelines as Topic
