First Cholesterol Guidelines Update Since 2018: Check Earlier, Treat Sooner, and Aim Lower

Top Cardiologist Andrew Ambrosy explains the updated guidelines that change who gets tested, who gets treated, and what number to aim for

SAN FRANCISCO, July 21, 2026 /PRNewswire/ -- Cardiologist Andrew P. Ambrosy, MD, MPH, today walked through the updated cholesterol treatment guidelines, the first rewrite since 2018. The headline for patients, he said, comes down to three shifts: cholesterol is being checked earlier in life, treatment is being offered to people at lower levels of risk, and a specific LDL number is once again the goal.

Low-density lipoprotein (LDL), or "bad" cholesterol, is the No. 1 culprit in causing plaque to build up in a person's arteries. One in four U.S. adults have elevated LDL levels. Plaque does not appear overnight, but rather accumulates quietly over decades, which is why the guidelines now push the first screening earlier than most people expect. Research shows that people who have inherited high cholesterol from their parents can start building up plaque in childhood, Ambrosy said, and catching it early can fast-track treatment and prevent serious health issues later in life.

The stakes are high. Cardiovascular disease is the No. 1 killer in the U.S., responsible for 1 in 5 deaths, or roughly 700,000 largely preventable deaths annually.

"Cholesterol is a lifetime exposure, not a midlife problem," Ambrosy said. "The arteries are keeping score the whole time. Most cardiovascular deaths are preventable, and the earlier we know the number, the more we can do about it."

The new cholesterol treatment guidelines were issued recently by the American Heart Association, the American College of Cardiology and several other medical groups, and they draw on data from roughly 6.6 million people. The 2018 version was based on about 26,000.

A first cholesterol test is now reasonable in grade school, between roughly ages 9 and 11. The point is not to medicate children, Ambrosy said, but to catch familial hypercholesterolemia, an inherited condition that affects about 1 in 250 people and runs silently through families. After that first test, the updated guidelines call for regular testing to kick in at 19-years-old and then every five years, said Ambrosy.

The biggest change for most adults is who gets offered treatment. Because the guidelines now weigh risk over a 30-year horizon rather than only the next 10 years, patients who used to have LDL levels that looked reassuringly low-risk on paper are now being flagged sooner, often for a statin. "A 40-year-old with a bad lipid profile is not low risk. They are early," Ambrosy said. Beyond that, he noted that the new guidelines include:

• The return of a number to aim for. For years, guidelines steered doctors away from chasing a specific LDL reading and toward simply prescribing the right intensity of statin. Explicit targets are back, and they are lower: a 20 percent lower LDL target reading for at-risk patients, meaning those who have had a heart attack or stroke or who have other risk factors, like those who have diabetes or smoke. The new target LDL is 55 mg/dL, or lower. Previously, the target was 70 mg/dL or lower. The target LDL level for adults who are not at-risk should be 100 mg/dL, or below, said Ambrosy, citing the new guidelines.

"A target gives you and your doctor something concrete to work toward. You can measure it and you can tell whether the plan is working," said Ambrosy. "And within the range we are talking about, lower has consistently been better."

• A once-in-a-lifetime test most people have never had. When visiting their doctor for a cholesterol screening, adults should also ask to have their lipoprotein, or Lp(a), biomarker tested. This is a test that likely wasn't done previously but, new research shows, is important, as high Lp(a) levels increase the likelihood of inflammation, which can lead to blood clots and cause a heart attack. The guidelines now advise checking it at least once, because a high result can move someone into a higher risk category and change the treatment plan.

The Lp(a) reading is also important to know because unlike LDL levels, this biomarker cannot be lowered through exercise, diet or statins, Ambrosy noted. "It is a card you were dealt," he said. "You cannot change that number, but knowing it tells us how aggressively to manage everything else." Drugs that lower Lp(a) directly are in late-stage clinical trials.

• A longer view of risk. The new guidelines take a preventative approach rather than a reactive one, Ambrosy said. That is why the stepped-up guidelines call for getting a 10 and 30-year risk estimate based on an updated risk calculator, called Predicting Risk of Cardiovascular EVENTs, or PREVENT, drawing on the screening results and health history of the patient. Previously, just a 10-year risk assessment was deemed sufficient. PREVENT also factors in kidney and metabolic health, reflecting how tightly those systems are tied to the heart.

Ambrosy said unchanged is the sound advice that individuals should eat a healthy diet, avoid smoking, and get plenty of exercise and sleep. No prescription substitutes for that foundation.

"It is great advice to take a long-term, preventative approach to one's heart health, and that begins with maintaining a long-term eye on one's LDL levels," Ambrosy said. "Know your LDL, know your Lp(a) once, and understand your risk over decades rather than just the next few years. That is a conversation worth having at your next visit, whatever your age."

ABOUT DR. AMBROSY

Andrew P. Ambrosy, MD, MPH, is a physician-scientist at the Kaiser Permanente Northern California Division of Research, with clinical and research expertise in cardiovascular, renal, and metabolic conditions. Dr. Ambrosy's work focuses on generating real-world evidence through health services research, delivery science, and both traditional and pragmatic randomized controlled trials.

SOURCE Andrew P. Ambrosy, MD, MPH