ACC/AHA Issue Updated Guideline for Managing Lipids, Cholesterol

Healthy lifestyle habits, earlier treatment to lower long-term exposure to plaque-causing lipids, new cholesterol target goals, selective use of coronary calcium scoring, lipoprotein(a) and apolipoprotein B testing, new treatments, and guidance for managing lipids in specific populations among key focus areas

WASHINGTON and DALLAS, March 13, 2026 /PRNewswire/ -- The American College of Cardiology (ACC), the American Heart Association and nine other leading medical associations, today issued an updated guideline for the management of dyslipidemia—abnormal levels of one or more types of lipids or lipoproteins in the blood, including cholesterol and triglycerides. It is estimated 1 in 4 U.S. adults has high levels of low-density lipoprotein-cholesterol (LDL-C), which increase the risk of heart attack and stroke.

The guideline consolidates evidence-based recommendations for managing dyslipidemias into one document, offering a comprehensive "one-stop shop" for how to best assess and treat various blood lipids to effectively lower an individual's risk of developing atherosclerotic cardiovascular disease (ASCVD). ASCVD is caused by buildup of fatty deposits in the arteries and is the leading cause of death globally. The document was jointly published today in JACC, the flagship journal of the American College of Cardiology, and Circulation, the flagship journal of the American Heart Association.

A major focus of the guideline is earlier intervention through healthy lifestyle changes, such as maintaining a healthy weight, engaging in regular physical activity, avoiding tobacco products, prioritizing healthy sleep habits and taking cholesterol-lowering medication when recommended by a health care professional. In addition, the guideline reinforces lower LDL-C goals and percent reduction based on risk to reduce lifetime exposure to unhealthy lipids and the risk of heart attack and stroke.

"We know 80% or more of cardiovascular disease is preventable and elevated LDL cholesterol, sometimes referred to as 'bad' cholesterol, is a major part of that risk," said Roger Blumenthal, MD, FACC, FAHA, chair of the guideline writing committee, director of the Johns Hopkins Ciccarone Center for the Prevention of Heart Disease and the Kenneth J. Pollin Professor of Cardiology at Johns Hopkins Hospital in Baltimore. "While we want to try to optimize healthy lifestyle habits as the first step to lower cholesterol, we realize that if lipid numbers aren't within the desirable range after a period of lifestyle optimization, we should consider adding lipid-lowering medication earlier than we would have considered 10 years ago. And lower LDL cholesterol for longer, just like lower blood pressure for longer, results in much greater protection against future heart attack and stroke risk."

New to the dyslipidemia guideline is the use of a newer, more contemporary cardiovascular disease risk calculator—Predicting Risk of Cardiovascular Disease EVENTs (PREVENT)—now recommended for primary prevention of ASCVD. The PREVENT-ASCVD equations are designed for adults ages 30-79 years without known ASCVD or subclinical atherosclerosis and with LDL-C 70–189 mg/dL to estimate 10- and 30- year risk of heart attack or stroke and guide lipid-lowering therapy. Lipid-lowering therapy includes statins and other newer treatments in addition to lifestyle management, all aimed at lowering lipid levels.

Older risk scores like the Pooled Cohort Equations overestimated the 10-year risk of a heart attack and stroke by 40%-50%, Blumenthal explained. The updated risk categories from the PREVENT-ASCVD equations classify 10-year ASCVD risk as low (<3%), borderline (3% to <5%), intermediate (5% to <10%), and high (10% or higher). These risk categories guide treatment decisions, including whether to initiate statin therapy and the recommended intensity of lipid-lowering therapy.

"With this new assessment tool, we can better estimate cardiovascular risk using health information already obtained during an annual physical—cholesterol, blood pressure readings and other personal information such as age and health habits—and then further personalize the risk score for each individual by looking at 'risk enhancers,' which can help guide the need for lipid-lowering therapy," Blumenthal said.

Such risk enhancers include a family history of heart disease; chronic inflammatory conditions (e.g., lupus or rheumatoid arthritis); cardiometabolic conditions such as overweight/obesity, diabetes or chronic kidney disease; higher-risk ancestry such as South Asian or Filipino ancestry or other ancestral groups with an enhanced risk for developing atherosclerosis; and reproductive risk markers, including early menopause, preeclampsia and gestational diabetes. Additional markers, including lipoprotein(a) [Lp(a)], apolipoprotein B (apoB), high-sensitivity C-reactive protein (hsCRP) and elevated triglycerides, can be used to refine an individual's ASCVD risk.

"Having healthy LDL-cholesterol levels or high-density lipoprotein-cholesterol (HDL-C), traditionally thought of as 'good' cholesterol, isn't necessarily a 'get out of jail free' card," Blumenthal said. "Measuring other biomarkers can give a more complete picture of someone's cardiovascular risk and help inform decisions about whether lipid-lowering therapy is needed sooner rather than later or if more intensive therapy is warranted."

The new guideline recommends the consideration of additional tests, when appropriate, to improve cardiovascular risk assessment and assess if more intensified LDL-C lowering and management of other risk factors is needed. These include:

• Selective use of a non-contrast coronary artery calcium (CAC) scan. This can be used to check for early or subclinical calcium and plaque buildup in the walls of the heart's arteries when there remains uncertainty about a person's true risk. It is recommended for men age 40 and older and women age 45 and older with borderline or intermediate 10-year risk of heart attack or stroke if knowing CAC will help with the decision to prescribe a statin or not. Having any amount of coronary artery calcium supports an LDL-C goal of less than 100 mg/dL—with lower LDL-C target levels with higher amounts of calcium.
  
  
• Lipoprotein (a). Lp(a) should be measured at least once in adulthood. Lp(a) levels are largely genetically determined and remain relatively stable over a lifetime. High Lp(a) (125 nmol/L or greater or 50 mg/dL or greater) is associated with about a 1.4-fold increased long-term risk of heart attack or stroke. An Lp(a) of 250 nmol/L is associated with at least a two-fold increased long-term risk of heart attack or stroke. Lifestyle changes minimally affect Lp(a) levels, so repeat testing is generally not needed.
  
  
• Apolipoprotein B. Measuring apoB may be used to assess any residual ASCVD risk and guide treatment among people with cardiovascular-kidney-metabolic syndrome, Type 2 diabetes, high triglycerides or known cardiovascular disease who have reached their LDL-C and non-HDL-C goals. ApoB may be a more accurate risk marker than LDL-C in these groups of people.

LDL-C cholesterol and non-HDL-C goals are back in the new guideline. To prevent a first heart attack or stroke, the LDL-C goal should be less than 100 mg/dL for those at borderline or intermediate risk and less than 70 mg/dL in those at high risk. For individuals with ASCVD who are at very high risk of ASCVD events, the LDL-C goal should be less than 55 mg/dL for secondary prevention of cardiac events.

"In general, lower LDL is better, especially for people at increased risk for a heart attack or stroke," said Pamela B. Morris, MD, FACC, FAHA, vice-chair of the guideline writing committee and the Paul V. Palmer chair of cardiovascular disease prevention and director of the Seinsheimer Cardiovascular Health Program at The Medical University of South Carolina. "Clinical trials have clearly demonstrated significant benefits for reduction in cardiovascular events when LDL-C levels are even lower than recommended in previous guidelines."

If LDL-C levels are not adequately lowered by healthy lifestyle habits and statin therapy, which remains the foundation of lipid-lowering and risk reduction, the guideline recommends the addition of non-statin therapies. Depending upon the level of risk and patient characteristics, evidence-based options include ezetimibe and/or bempedoic acid (a newer oral agent) or a PCSK9 monoclonal antibody, an injectable therapy. Inclisiran, another injectable option that requires less frequent injections, is still being studied in clinical trials to determine whether the associated LDL-C lowering translates into better outcomes and fewer cardiac events.

The guideline also outlines treatment for hypertriglyceridemia—abnormally high levels of triglycerides. Lifestyle changes and statin therapy remain the mainstay of treatment here as well due to the increased risk of ASCVD. However, other therapies may be needed based on an individual's ASCVD and pancreatitis risk.

Special considerations are recommended to optimize lipid management in certain adults at increased risk of heart disease. For example:

• Initiating lipid-lowering therapy for people age 40 or older who have chronic kidney disease (stage 3 or higher), HIV or Type 1 or Type 2 diabetes
  
  
• Continuing lipid-lowering therapy in people being treated for cancer, unless contraindicated
  
  
• Deferring most lipid-lowering therapies during conception, pregnancy and lactation

In addition, the guideline notes that high cholesterol can begin to impact heart disease risk even in childhood and adolescence. Children may have high cholesterol due to inherited conditions or lifestyle habits. Cholesterol screening is recommended for all children between the ages of 9-11 years not previously screened to help assess risk and guide care, in collaboration with clinicians, parents and caregivers.

"Implementation of this important new guideline by clinicians will be critical to reduce the burden of cardiovascular disease in the future. Improved risk assessment tools with the PREVENT-ASCVD equations, selective use of CAC scoring and measurement of lipoprotein(a) allow us to personalize treatment of those individuals at increased risk. The evidence base continues to grow and has demonstrated that people who maintain low levels of LDL cholesterol and triglycerides at earlier ages are much less likely to develop atherosclerotic disease decades later," Morris said. "Taking action early in life is critical because high cholesterol begins to impact your heart disease risk even in adolescence."

The new guideline was developed in collaboration with and is endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation, Association of Black Cardiologists, American College of Preventive Medicine, American Diabetes Association, American Geriatrics Society, American Pharmacists Association, American Society for Preventive Cardiology, National Lipid Association and Preventive Cardiovascular Nurses Association.

Additional Resources:

• After March 13, 2026, view the manuscript online in and JACC and Circulation.
• JACC.org Guideline Hub (available Wed., March 18, 2026 at 10 am ET)
• American Heart Association Guideline Hub for Professionals (available at 2 p.m. ET, Fri., March 13, 2026)
• JACC.org Dyslipidemia Guideline-at-a-Glance (available Wed., March 18, 2026 at 10 am ET)
• Editorial: Clinical Guidelines as a Continuous Work in Progress: Moving at the Speed of Science online in JACC and Circulation (available at 2 p.m. ET, Fri., March 13, 2026)
• Follow the ACC at @ACCinTouch
• Follow American Heart Association/American Stroke Association news on X @HeartNews
• Follow news from the ACC's flagship journal JACC @JACCJournals
• Follow news from the American Heart Association's flagship journal Circulation @CircAHA

The American College of Cardiology (ACC) is a global leader dedicated to transforming cardiovascular care and improving heart health for all. For more than 75 years, the ACC has empowered a community of over 60,000 cardiovascular professionals across more than 140 countries with cutting-edge education and advocacy, rigorous professional credentials, and trusted clinical guidance. From its world-class JACC Journals and NCDR registries to its Accreditation Services, global network of Chapters and Sections, and CardioSmart patient initiatives, the College is committed to creating a world where science, knowledge and innovation optimize patient care and outcomes. Learn more at www.ACC.org or connect on social media at @ACCinTouch.

The American Heart Association is a relentless force for a world of longer, healthier lives. Dedicated to ensuring equitable health in all communities, the organization has been a leading source of health information for more than one hundred years. Supported by more than 35 million volunteers globally, we fund groundbreaking research, advocate for the public's health, and provide critical resources to save and improve lives affected by cardiovascular disease and stroke. By driving breakthroughs and implementing proven solutions in science, policy, and care, we work tirelessly to advance health and transform lives every day. Connect with us on heart.org, Facebook, X or by calling 1-800-AHA-USA1.

SOURCE American College of Cardiology