Three studies using National Health and Nutrition Examination Survey (NHANES) data published July 20 in JAMA provide new insights into LDL-C treatment goals under the 2026 ACC/AHA Guideline on the Management of Dyslipidemia. Together, the studies estimate how many adults have LDL-C levels above guideline-recommended goals, how many may now be eligible for lipid-lowering therapy (LLT), and where treatment gaps remain.

Using data from 24,000 patients included in NHANES between 1999 and 2020 and focusing on adults aged 40-79 years, Allison W. Peng, MD, et al., found that cardiovascular risk would be reclassified in 22% when using the PREVENT risk equations recommended by the 2026 dyslipidemia guideline, compared with the pooled cohort equations. Overall, 14% moved to a lower risk category and 7% moved to a higher risk category. The proportion with borderline risk increased (18% vs. 13%), while the proportions in the intermediate-risk (20% vs. 25%) and high-risk groups (11% vs. 12%) decreased. The prevalence of the 10-year low-risk group stayed nearly the same (50.6% vs. 50.4%).

Men, non-Hispanic Black adults and current smokers were most likely to be reclassified as lower risk while women and people with diabetes were most likely to be moved to a higher risk category.

"By increasing the number of borderline-risk individuals and decreasing those at intermediate to high risk, the [2026 dyslipidemia guideline] shifts the focus to emerging risk markers, subclinical disease with coronary artery calcium scoring, and shared decision-making to guide cardiovascular prevention and lipid management," write Peng and colleagues. They add that the guideline "may result in opportunities for consideration of more personalized cardiovascular risk assessment."

In a second study, Shady Abohashem, MD, MPH, and colleagues used NHANES data from 2021-2023 to assess treatment gaps in LLT among participants aged 30-79 years. Among 2,313 participants in the primary prevention cohort, 32% had LDL-C levels above the guideline-recommended goals, with prevalence increasing across higher PREVENT-calculated ASCVD risk categories (10% low-risk; 64% borderline or intermediate-risk; 83% high-risk). Among adults with established ASCVD, 80% had LDL-C levels above goal. Researchers also found that 38% of those in the secondary prevention cohort and 76% of those in the primary prevention cohort were not receiving LLT.

"Observed treatment gaps likely reflect multiple factors, including limited patient awareness, clinical inertia, and barriers to access or adherence," write the authors.

A third study, focused on primary prevention of ASCVD, found that 21.5 million individuals were newly eligible for statin therapy based on the lower thresholds in the 2026 dyslipidemia guideline. According to Timothy S. Anderson, MD, MAS, et al., this expansion in the statin-eligible population mostly included younger participants and those at lower risk.

The analysis included 4,366 NHANES participants aged 30-79 years without known ASCVD who were enrolled between 2017 and 2023. Researchers compared statin eligibility under the 2018 guideline on the management of blood cholesterol and the 2026 dyslipidemia guideline. The patients were about 51 years old (weighted mean age) and half were women; 62% were White, 16% Hispanic, 11% Black and 6% Asian.

Results also showed that 88 million adults – nearly two-thirds of adults aged 30-79 years without known ASCVD – qualified for statin therapy using criteria in the 2026 dyslipidemia guideline. Statin eligibility increased sharply by age, with 93% of adults aged 70-79 years and 85% of those aged 60-69 years eligible compared with 11% of adults aged 30-39 years.

Together, these studies "confirm the long-standing observation that a large percentage of U.S. adults aged 30 years or older are candidates for guideline-directed LLT, and many who are currently taking LLT are not reaching new (or previous) LDL-C goals," observe Philip Greenland, MD, FACC, and Karen E. Lasser, MD, MPH, in an accompanying editorial comment. Mass public health campaigns may be effective in addressing this, they write, noting that patients should be encouraged to ask during medical visits, "Should I be taking a statin?"