2026 ACC/AHA Guidelines Update on the Management of Dyslipidemia
Special Insights
Contributing Authors:
Riley Christian, PharmD
Beatriz Jimenez Cadilla, PharmD, BCACP, CDCES, CPh
Kayla Mitzel, PharmD
Kelly Rubi, PharmD, CPh, BCPS, BCACP
Amanda Gronniger, PharmD, CPh, BCCP
The release of the 2026 ACC/AHA/Multisociety Guideline on the Management of Dyslipidemia marks an important evolution in cardiovascular risk reduction.
This update introduces an updated approach to risk assessment with a novel scoring system called PREVENT, recommends more aggressive targets for low-density lipoprotein cholesterol (LDL-C), and advises at least one measurement of lipoprotein(a) [Lp(a)] to help identify patients at elevated cardiovascular risk.
A New Approach to Hyperlipidemia Screening – The Earlier the Better
The 2026 guidelines place increased emphasis on earlier identification of lipid disorders across the lifespan, recognizing that cumulative exposure to atherogenic lipoproteins is a major driver of ASCVD risk.
Universal screening is recommended at ages 9-11 years old to identify familial hypercholesterolemia and other lipid disorders.
Screening should be completed as young as 2 years of age if there is a family history of premature ASCVD, severe hypercholesterolemia, or familial hypercholesterolemia.
Lipids should continue to be checked regularly, with lipid screening again at 19 years of age and at least every 5 years thereafter.
The 2026 guideline moves beyond a one-size-fits-all approach and toward a more personalized, risk-based strategy... Treatment is now focused on more aggressive LDL-C lowering, combination therapy, and earlier prevention strategies.
From PCE Scoring to the PREVENT Risk Assessment Model
The guideline introduces the Predicting Risk of cardiovascular disease EVENTs (PREVENT™) risk assessment model, which expands upon the prior Pooled Cohort Equation (PCE) by incorporating both 10-year and 30-year CVD, ASCVD, and HF risk estimates.
The PREVENT-ASCVD risk equation should be used for adults 30-79 years of age who present with fasting or non-fasting LDL-C levels of 130 to 320mg/dL to estimate both 10-year and 30-year risk of ASCVD events.
This allows clinicians to better identify younger patients who may benefit from earlier preventive strategies, even when short-term risk appears low. This model supports earlier statin initiation with the goal to protect the heart earlier when lipid load is lower and before plaque burden is high.
Additionally, the guidelines emphasize the “CPR” framework for primary prevention in adults:
- Calculate 10-year ASCVD risk
- Personalize the estimated risk to patient based on other specific factors not included in the PREVENT-ASCVD equation
- Reclassify with selective use of coronary artery calcium (CAC) scored and reassess therapy regimen
Advancements in LDL-C Goals – Lower is Better
One of the most notable changes is the reintroduction of specific LDL-C treatment goals, with more aggressive targets for high-risk populations.
Previous guidelines recommended percent reductions in LDL for different patient populations, including patients with diabetes and/or ASCVD. However, there were some gaps in primary prevention for certain adult patients, and these new guidelines address the need for earlier screening and intervention through lifestyle modifications and pharmacotherapy.
Patients with very high-risk atherosclerotic cardiovascular disease (ASCVD) are defined as having > 2 major ASCVD events or 1 major ASCVD event and > 2 high-risk conditions.
Major ASCVD events are defined as acute coronary syndrome within the past 12 months, history of myocardial infarction, history of ischemic stroke, and symptomatic peripheral artery disease.
High risk conditions include age > 65, coronary bypass or percutaneous intervention, current smoker, diabetes, history of congestive heart failure, hypertension, and LDL-C > 100 mg/dL despite maximally tolerated statin + ezetimibe.
These patients are now recommended to achieve an LDL-C of <55 mg/dL and a non-HDL-C < 85 mg/dL. Those with ASCVD and not very high risk are defined as those with clinical ASCVD and do not meet the very-high risk criteria as described above.
Both patients with ASCVD and not very high risk and those who are high-risk without established ASCVD, defined as a PREVENT-ASCVD score of > 10%, should target an LDL-C of <70 mg/dL and non-HDL-C < 100 mg/dL.
These updated LDL-C and Non-HDL-C goals reinforces the concept that “lower is better, and earlier is better,” with cumulative LDL exposure over time playing a critical role in long-term cardiovascular outcomes.
Please see below a brief summary of updated LDL goals:
Re-emphasis on CAC Scoring as a Therapeutic Decision-Making Tool
The 2026 guidelines re-emphasize the utilization of coronary artery calcium (CAC) scoring as a valuable tool for guiding therapeutic decision-making.
CAC scoring provides a more individualized measure of atherosclerotic disease by directly quantifying calcified plaque burden in the coronary arteries.
Importantly, CAC scoring can help resolve clinical uncertainty in intermediate-risk patients, support shared decision-making, and improve adherence by offering a visual and objective marker of disease.
Advanced Biomarkers – Understanding Residual Risk
Additional lipoprotein goals include apolipoprotein B (ApoB) and lipoprotein (a) (Lp(a)). While LDL remains one of the major lipid markers for assessment of ASCVD risk and therapeutic goals, ApoB and Lp(a) provide deeper insights for ASCVD risk assessment.
ApoB testing is now noted as a useful tool in assessing patient risk and guiding treatment selection once LDL-C and non-HDL-C goals are met.
This testing can be particularly useful for patients with elevated triglycerides (>200 mg/dL), diabetes, or low achieved LDL-C (<70 mg/dL), as it can be used to identify hidden cardiovascular risk and guide therapy beyond traditional lipid panels.
ApoB is present on all major lipoproteins that can promote atherosclerosis, including LDL-C, VLDL-C, IDL, and lipoprotein(a), and its level reflects the total number of atherogenic particles.
The number of atherogenic particles is more directly linked to arterial wall penetration and plaque formation than cholesterol content alone. ApoB levels elevated beyond the normal range are a more accurate reflection of true ASCVD risk.
Currently, there are no FDA approved treatments that target ApoB specifically, highlighting an unmet need for more targeted treatment options.
The 2026 guidelines recommend the following ApoB goals for ASCVD risk reduction:
Furthermore, lipoprotein(a) [Lp(a)] should be measured at least once in all adults to identify individuals at higher risk of ASCVD. Lp(a) has proatherogenic and proinflammatory effects that may play a role in elevated ASCVD risk.
The guideline states that Lp(a) concentrations of 50 mg/dL (125 nmol/L) or greater is associated with an estimated 40% relative risk increase in ASCVD compared with those of lower Lp(a) concentrations.
Statin therapy has no clinically meaningful effect on Lp(a) concentrations, which represents a current limitation in dyslipidemia management.
There is growing emphasis on adjunctive and targeted therapies for Lp(a) reduction, as there are currently five agents in the pipeline that target the reduction of Lp(a).
Olpasiran, zerlasiran, and lepodisiran are small interfering RNA molecules, pelacarsen is an antisense oligonucleotide, and muvalaplin is a small molecule inhibitor.
All these agents inhibit the hepatic production of Lp(a), and of these agents, pelacarsen, olpasiran, and lepodisiran are currently in phase 3 cardiovascular outcomes trials to determine whether lowering Lp(a) translates into reduced ASCVD events.
Established Pillars and Expansion of Therapy Options
Lipid lowering therapy (LLT) plays a vital role in the optimal management of patients with hypercholesterolemia and/or elevated ASCVD risk.
Statins remain the cornerstone of LLT for reduction of LDL and ASCVD risk. They are effective, with a variety of LDL-lowering potential ranging from 30% to >50% LDL reduction.
The benefits of statin therapy, including ASCVD event rate reduction, greatly outweighs the risks. However, it is important that clinicians remain vigilant to potential side effects that may require lower doses or alternative therapies.
Non-statin LLT have been underutilized due to several factors, including therapeutic inertia, barriers to medication access, and misconceptions that only statins reduce ASCVD risk.
Non-statin LLT include medications like ezetimibe, bempedoic acid, proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, inclisiran, and fibrates.
Non-statin LLT that have been shown to reduce ASCVD events include bempedoic acid in primary prevention and PCSK9 inhibitors for secondary prevention.
While the 2018 guidelines recommended the addition of ezetimibe prior to trial of PCSK9 inhibitors, this update provides recommendation that either ezetimibe, PSCK9 inhibitors, or bempedoic acid may be added as a second-line agent for LLT.
Inclisiran may be reasonable for management of hypercholesterolemia in patients not at goal despite maximally tolerated statin, with or without ezetimibe, or intolerance to PCSK9 inhibitors. Thus, the guidelines emphasize the need for LLT intensification through combination therapy.
Moving Beyond LDL-C Control – Targeting Underlying Risk of Elevated Triglycerides
For adults with persistently elevated triglyceride levels > 150 mg/dL, first-line therapy remains aggressive lifestyle modification, including weight loss of 5% to 10% of body weight if overweight or obese, reduced intake of added sugars, alcohol and saturated, increased physical activity, which can significantly lower triglyceride levels when adhered to consistently.
In ASCVD patients with persistently elevated triglycerides (150-999 mg/dL) and above LDL-C and non-LDL-C goals, intensification of statin therapy is recommended to achieve a triglyceride goal of <135 mg/dL.
In patients with persistent elevations in triglyceride levels despite maximally tolerated statin therapy, particularly those with ASCVD or diabetes, additional therapies such as icosapent ethyl may be considered for further risk reduction.
The REDUCE-IT trial showed that high-dose icosapent ethyl reduced major adverse cardiovascular outcomes in patients with elevated triglyceride levels despite statin therapy by approximately 25%, with an absolute risk reduction of about 4.8% over a median follow-up of 4.9 years.
Furthermore, olezarsen is an apoC3 inhibitor recommended for patients with familial chylomicronemia syndrome and fasting triglyceride level > 1000 mg/dL.
Overall, hypertriglyceridemia management in 2026 is no longer one-size-fits-all but instead a tiered strategy aligning triglyceride levels and ASCVD risk with progressively intensified therapy.
Top Take-Home Messages
- Treatment of dyslipidemia should start earlier in young adulthood with an LDL-C of > 160 mg/dL or a strong family history of premature ASCVD
- PREVENT-ASCVD equation for primary prevention to help assess risk
- LLT can be considered if 10-year risk is borderline (3-<5%)
- LLT should be considered if 10-year risk is intermediate (5-<10%)
- ApoB is useful when LDL-C and non-HDL-C goals are met, especially in patients with:
- TG > 200 mg/dL
- Diabetes
- Low achieved LDL-C (<70 mg/dL)
- Lp(a) should be measured in each adult at least once
- Considered a risk enhancing factor when levels are >50 mg/dL (125 nmol/L)
- CAC score to improve risk assessment and guide LDL-C and non-HDL-C goals
- Men >40 years of age
- Women >45 years of age
- LLT is recommended for primary prevention in adults ages 40-75 years old with diabetes, CKD stage 3 or 4, or HIV, regardless of LDL-C level
- Secondary prevention goals:
- Very high risk: LDL-C <55 mg/dL, non-HDL-C <85 mg/dL
- Not very high risk: LDL-C <70 mg/dL, non-HDL-C <100 mg/dL
- If triglycerides are persistently elevated:
- Statin and lifestyle modifications are the foundation of therapy to reduce ASCVD risk
- Consider TG lowering therapies, especially in patients with TG > 1000 mg/dL to prevent pancreatitis
In summary, the 2026 guideline moves beyond a one-size-fits-all approach and toward a more personalized, risk-based strategy.
By incorporating tools such as advanced biomarker testing with ApoB and [Lp(a)] and the PREVENT risk assessment model, clinicians are better equipped to identify high-risk patients earlier and tailor therapy accordingly.
Treatment is now focused on more aggressive LDL-C lowering, combination therapy, and earlier prevention strategies.
References:
- 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;153(17): doi: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: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines [published correction appears in Circulation. 2019 Jun 18;139(25):e1182-e1186] [published correction appears in Circulation. 2023 Aug 15;148(7):e5]. Circulation. 2019;139(25):e1082-e1143. doi:10.1161/CIR.0000000000000625
- Wiggins BS, Barac A, Benziger CP, et al. 2026 Dyslipidemia guideline-at-a-glance. J Am Coll Cardiol. 2026;87(12):e1-12. doi:10.1016/j.jacc.2025.11.017
Disclaimer: Artificial intelligence–based tools were used to support the proofreading and refinement of this document. Final content review and approval were completed by the authors.
This article was submitted for the FLORxIDA Times | July 2026, Issue 22.
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