2026 ACC/AHA Cholesterol Guideline (Dyslipidemia): Quick Reference
The bottom line of the 2026 ACC/AHA guideline on dyslipidemia, which replaces the 2018 cholesterol guideline: risk from the PREVENT-ASCVD equations, LDL cholesterol goals again, a one-time lipoprotein(a) test for every adult, and a clearer path to nonstatin therapy.
At a glance
- Estimate 10- and 30-year ASCVD risk with the PREVENT-ASCVD equations in adults 30 to 79.
- LDL-C goals are back: under 100 mg/dL at borderline or intermediate risk, under 70 at high risk, under 55 for very high-risk ASCVD.
- Measure lipoprotein(a) at least once in every adult; one result is usually enough for life.
- Use coronary artery calcium scoring selectively when the decision is uncertain; any calcium supports a goal under 100.
- If a statin and lifestyle do not reach the goal, add ezetimibe, bempedoic acid or a PCSK9 monoclonal antibody.
Key recommendations
Risk assessment
Estimate 10-year and 30-year ASCVD risk with the PREVENT-ASCVD equations in adults 30 to 79 without ASCVD, instead of the pooled cohort equations.
Measure lipoprotein(a) at least once in adulthood; because levels are mostly genetic, repeat testing is usually not needed.
Use selective noncontrast coronary artery calcium scoring for men over 40 and women over 45 at borderline or intermediate risk when the treatment decision is uncertain.
Who to treat
Offer LDL-lowering therapy after a risk discussion at intermediate 10-year risk (5% to under 10%), and consider it at borderline risk (3% to under 5%).
Start lipid-lowering therapy in adults 40 and older with diabetes (type 1 or 2), chronic kidney disease stage 3 or worse, or HIV.
Consider medication early in young adults with LDL-C of 160 mg/dL or more or a strong family history of premature ASCVD, and in children with familial hypercholesterolemia.
Goals
Primary prevention: LDL-C under 100 mg/dL at borderline or intermediate risk and under 70 mg/dL at high risk (10-year risk of 10% or more).
Clinical ASCVD: LDL-C under 70 mg/dL, and under 55 mg/dL for patients at very high risk. Non-HDL-C goals are used alongside them.
Any coronary calcium supports an LDL-C goal under 100 mg/dL, with lower goals as the calcium score rises.
Therapy
Statins plus lifestyle remain the foundation; when the goal is not reached, add a nonstatin: ezetimibe, bempedoic acid or a PCSK9 monoclonal antibody, chosen by risk and patient factors.
Apolipoprotein B can be used to judge residual risk in patients with diabetes, high triglycerides, cardiovascular-kidney-metabolic syndrome or ASCVD who are already at their LDL-C and non-HDL-C goals.
Triglycerides
For persistently high triglycerides, use lifestyle measures and statins first; add triglyceride-lowering therapy at 1,000 mg/dL or more to prevent pancreatitis.
Special situations
Keep lipid-lowering therapy going during cancer treatment unless there is a contraindication; defer most lipid-lowering drugs around conception, in pregnancy and while breastfeeding.
How to read the grades ACC/AHA
Class of recommendation: 1 is strong (recommended), 2a is moderate (reasonable), 2b is weak (may be considered), 3 means no benefit or harm (do not do it). Level of evidence: A is high quality (several randomized trials or their meta-analyses), B-R is moderate from randomized trials, B-NR is moderate from nonrandomized studies, C-LD is limited data, C-EO is expert opinion.
What changed
Compared with the 2018 AHA/ACC multisociety cholesterol guideline.
Risk tool
- Before
- Pooled cohort equations, with statin decisions mainly at 7.5% or more 10-year risk.
- Now
- PREVENT-ASCVD equations, with treatment discussed from 3% to 5% (borderline) and recommended at 5% to 10% (intermediate).
Treatment goals
- Before
- Percent LDL-C reduction, with 70 mg/dL as a threshold for adding nonstatins in very high-risk patients.
- Now
- Explicit LDL-C and non-HDL-C goals: under 100, under 70 and under 55 mg/dL by risk.
Lipoprotein(a)
- Before
- A risk-enhancing factor when measured.
- Now
- Measure at least once in every adult.
Coronary calcium
- Before
- Used to reclassify intermediate risk and decide on statins.
- Now
- Also sets the LDL-C goal: any calcium means under 100 mg/dL, with lower goals at higher scores.
Nonstatins
- Before
- Ezetimibe and PCSK9 inhibitors mainly for very high-risk ASCVD.
- Now
- Ezetimibe, bempedoic acid or a PCSK9 monoclonal antibody whenever the goal is not reached on a statin.
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Questions clinicians ask
Does the 2026 guideline bring back LDL targets?
Yes. It sets LDL-C goals by risk: under 100 mg/dL at borderline or intermediate risk, under 70 at high risk or with ASCVD, and under 55 for very high-risk ASCVD, with non-HDL-C goals alongside.
Who should have lipoprotein(a) measured?
Every adult, at least once. Because the level is mostly inherited, a single result is usually enough. A high level is a reason to treat other risk factors earlier and more firmly.
What happened to the 7.5% statin threshold?
The guideline now uses the PREVENT-ASCVD equations, which give lower estimates than the pooled cohort equations. Treatment is discussed from a 10-year risk of 3% to 5% and recommended from 5% to 10%.
Is inclisiran one of the recommended add-ons?
The guideline lists ezetimibe, bempedoic acid and PCSK9 monoclonal antibodies as the main nonstatin options and notes that outcome trials of inclisiran were still under way.
Sources
- 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. J Am Coll Cardiol. Published online March 13, 2026. doi.org/10.1016/j.jacc.2025.11.016
- Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol. Circulation. 2019;139:e1082-e1143. doi.org/10.1161/CIR.0000000000000625
Summarized in our own words by 2 Minute Medicine's physician editors from the source documents listed here. Strength and evidence grades are the guideline authors' own. This is a quick reference, not a substitute for the full guideline or for clinical judgment.
For health care professionals. 2 Minute Medicine is independent and is not affiliated with or endorsed by the societies that write these guidelines.
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