Clinical Updates · Cardiology
The 2026 ACC/AHA/AACVPR/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Dyslipidemia dropped this spring — and if you manage patients with cardiovascular risk in primary care, this one is going to change your practice. Here's what you need to know, translated for the clinic floor.
Whether you're seeing a 45-year-old with a new diabetes diagnosis, a 58-year-old post-MI patient not at LDL goal, or a young woman with a family history of premature heart disease, the 2026 guidelines give us clearer targets, updated risk tools, and several entirely new recommendations that simply didn't exist before. Let's break it down.
📋 Quick Context
This guideline is co-authored by 11 major professional organizations and replaces the 2018 ACC/AHA Cholesterol Guideline. It was approved in October–December 2025 and published in the Journal of the American College of Cardiology and Circulation. The evidence review covers literature through April 2025.
01 — Risk AssessmentThe PREVENT Equations Replace the Pooled Cohort Equations
This is the first and most operationally significant change you'll encounter. The old Pooled Cohort Equations (PCE) are out. The new PREVENT-ASCVD equations are now the standard for estimating 10-year cardiovascular risk in adults aged 30–79 without established ASCVD or subclinical atherosclerosis, with LDL-C between 70 and 189 mg/dL.
The PREVENT model is more contemporary, more inclusive, and incorporates additional cardiometabolic factors. Risk is now categorized into four tiers:
The guideline introduces a helpful framework called the "CPR" Model for primary prevention decision-making:
- Calculate 10-year ASCVD risk using PREVENT-ASCVD equations
- Personalize estimated risk by considering factors not included in the equations (risk enhancers, reproductive history, social determinants)
- Reclassify with selective use of CAC scoring and reassess treatment recommendations
🩺 NP Clinical Pearl
The PREVENT calculator is available free at tools.acc.org. Make it a habit to update this with every patient over 30 at their annual wellness visit. The new model also incorporates 30-year risk for patients aged 30–59, which is a meaningful addition for young patients who may feel "too young" to worry about cholesterol.
02 — Lab TestingNew Guidance on What to Measure (and Why It Matters)
Lp(a) — Now Recommended for Everyone, Once
This is a landmark change. For the first time, the guidelines give a Class I (COR 1) recommendation that all adults have lipoprotein(a) [Lp(a)] measured at least once in their lifetime for ASCVD risk assessment. Previously, this was reserved for select high-risk individuals.
⚠️ Why This Matters
Lp(a) ≥125 nmol/L (≥50 mg/dL) confers approximately 1.4× increased ASCVD risk. Levels ≥250 nmol/L (≥100 mg/dL) are associated with a ≥2-fold higher risk. Elevated Lp(a) should prompt more intensified LDL-C lowering and rigorous management of all other modifiable risk factors. Lp(a)-specific therapies are in trials — knowing your patient's level now matters.
ApoB — New Supporting Role in Monitoring
A new COR 2a recommendation supports measuring apolipoprotein B (apoB) in adults on lipid-lowering therapy — particularly those with ASCVD, cardiovascular-kidney-metabolic (CKM) syndrome, type 2 diabetes, and/or elevated triglycerides — once LDL-C and non-HDL-C goals are achieved. ApoB helps identify residual lipoprotein-related risk that a standard lipid panel may underestimate, especially in patients with elevated TG or low achieved LDL-C (<70 mg/dL).
Better LDL-C Calculation
The old Friedewald equation for calculating LDL-C is no longer preferred. The guidelines now recommend either the Martin/Hopkins equation or the Sampson/NIH equation as standard — both are significantly more accurate, especially at low LDL-C levels. Most modern lab systems and electronic health records have already transitioned to these methods, but verify with your lab.
03 — Primary PreventionTreat Earlier, Treat Smarter, Set Goals
The 2026 guidelines make a major philosophical shift: LDL-C and non-HDL-C treatment goals are back. The 2018 guideline moved away from specific targets toward percentage reductions. The 2026 guideline brings both — percentage reductions and specific numeric goals — depending on risk category.
💡 Key Shift for NPs
Borderline-risk patients (3–<5%) can now be treated — this is an upgrade from COR 2b (may be considered) to COR 2a (is reasonable). For intermediate-risk patients, statin initiation is a Class I recommendation. And for the first time, specific LDL-C target goals accompany statin intensity recommendations at every risk tier.
Reproductive Risk Markers Are Now Part of Risk Assessment
New for 2026: a COR 2a recommendation supports considering reproductive risk markers — including early menopause (<45 years), gestational hypertension, preeclampsia, gestational diabetes, and preterm delivery — when personalizing ASCVD risk assessment for primary prevention. These adverse pregnancy outcomes are now recognized as independent cardiovascular risk enhancers that should prompt earlier consideration of lipid-lowering therapy.
04 — CAC ScoringCoronary Artery Calcium Gets Expanded, Actionable Guidance
Coronary artery calcium (CAC) scoring receives its most detailed and actionable guidance to date. It's no longer just a tiebreaker when statin use is uncertain — it now generates its own treatment targets based on score severity.
Importantly, incidental CAC found on non-cardiac CT scans (pulmonary emboli workups, chest CTs, etc.) should now be factored into treatment decisions. AI-based algorithms are specifically mentioned as valid tools for detecting coronary atherosclerosis on noncardiac imaging — a forward-thinking addition that reflects real-world practice.
05 — Secondary PreventionLower Goals, More Tools
The 2026 guidelines take a notably more aggressive approach to secondary prevention. Most patients with established ASCVD should now be treated to an LDL-C goal of <55 mg/dL — a target that will require nonstatin therapy in many patients.
🔴 High Risk vs. Very High Risk
The 2026 guideline distinguishes between ASCVD patients who are "not at very high risk" (LDL goal <70 mg/dL and non-HDL <100 mg/dL) and those "at very high risk" (recent ACS, multiple ASCVD events, ASCVD + diabetes/CKD/HeFH — LDL goal <55 mg/dL and non-HDL <85 mg/dL). In practice, most of your established ASCVD patients will qualify for the <55 mg/dL target.
The Nonstatin Toolkit — Now with More Options
When maximally tolerated statin therapy isn't getting patients to goal, the guideline now explicitly supports a stepwise approach using:
Inclisiran is the newest addition to the guideline-endorsed toolkit. For patients who struggle with injection frequency or who cannot access or tolerate evolocumab/alirocumab, inclisiran's twice-yearly dosing offers a compelling alternative.
06 — Special PopulationsDiabetes, FH, CKD, HIV, and Cancer Survivors
Diabetes (Ages 40–75)
The foundational recommendation is unchanged — moderate-intensity statin therapy is COR 1 for all adults 40–75 with diabetes without established ASCVD. What's new: explicit LDL-C and non-HDL-C goals are now attached. The target is LDL-C <100 mg/dL and non-HDL-C <130 mg/dL. For those with multiple ASCVD risk factors, high-intensity statin therapy targeting LDL-C <70 mg/dL and non-HDL-C <100 mg/dL is COR 2a.
Familial Hypercholesterolemia (FH)
Several important updates for FH management:
- Standard risk calculators should not be used in HeFH (COR 3 — these patients are always at elevated risk regardless of what the calculator says)
- Genetic testing for pathogenic FH variants is reasonable in adults with LDL-C ≥190 mg/dL without secondary causes (COR 2a)
- For HeFH without ASCVD: goal LDL-C <70 mg/dL; with ASCVD: goal <55 mg/dL
- Homozygous FH (HoFH): evinacumab added as an option when LDL-C remains ≥100 mg/dL on max therapy including PCSK9 mAbs (COR 2b)
CKD Stage 3 or Higher with ASCVD
New COR 1 recommendation: these patients should receive high-intensity statin therapy ± ezetimibe ± PCSK9 mAb to achieve ≥50% LDL-C reduction with a goal of <55 mg/dL. This aligns CKD+ASCVD patients with the very high-risk secondary prevention tier.
People Living with HIV
A brand-new COR 1 recommendation: adults aged 40–75 living with HIV on stable antiretroviral therapy should receive statin therapy to reduce first ASCVD event risk and slow coronary atherosclerosis progression. This is a particularly important addition given the cardiovascular risk profile of this population.
Cancer Survivors
New COR 1: adult cancer survivors with life expectancy ≥2 years who otherwise qualify for lipid-lowering therapy should be treated the same as patients without cancer history. Don't withhold guideline-indicated therapy due to oncologic history alone.
07 — TriglyceridesUpdated Guidance Including New Therapies
Persistently elevated triglycerides deserve more attention under the 2026 framework. Key updates:
TG Management Highlights
TG 150–999 mg/dL with ASCVD: If LDL-C and non-HDL-C are above goal, intensify LDL-C lowering therapy first (COR 1).
TG ≥500 mg/dL: Refer to a registered dietitian nutritionist (RDN) for pancreatitis risk reduction.
TG 150–999 mg/dL + CKM syndrome features: RDN referral is also recommended.
Familial chylomicronemia syndrome (TG ≥1000 mg/dL): Olezarsen (an apoC3 inhibitor) is now COR 1 — the first guideline endorsement of this novel mechanism for pancreatitis prevention.
For adults 40–75 without ASCVD or diabetes but with persistently elevated TG (150–499 mg/dL), the guideline now recommends using PREVENT equations to estimate ASCVD risk and have a benefit-risk discussion about statin therapy — a new, proactive approach to this often-undertreated group.
08 — What's OutDietary Supplements — A Clear "No"
🚫 COR 3 — Do Not Recommend
For the first time, the guidelines include a Class III recommendation against dietary supplements for lowering LDL-C or triglycerides. This includes fish oil (for LDL/TG in non-pancreatitis settings), red yeast rice, berberine, plant sterols marketed as supplements, and other nutraceuticals. The evidence for meaningful cardiovascular benefit is limited and inconsistent. When patients ask about supplements, you now have guideline-level support for redirecting that conversation toward proven therapies and lifestyle changes.
09 — For Your Practice10 High-Yield Takeaways to Implement Now
Order an Lp(a) on every adult — once
This is now a Class I recommendation. Add it to your next comprehensive lipid panel for any patient who hasn't had one. It's a one-time test with lifelong relevance.
Switch your risk calculator to PREVENT-ASCVD
The PCE is no longer the recommended tool. Bookmark the ACC PREVENT calculator and use it for every primary prevention conversation.
Know your patients' non-HDL-C goals
Non-HDL-C targets are now paired with every LDL-C goal. Non-HDL-C = total cholesterol − HDL-C; goals are 30 mg/dL higher than the corresponding LDL-C goal at each tier.
Ask about adverse pregnancy outcomes in all women
Preeclampsia, gestational diabetes, preterm delivery, and early menopause are now formal risk enhancers. Add these to your cardiovascular history intake questions.
Don't stop at statin intolerance — use bempedoic acid
Bempedoic acid has an expanded role in 2026, including as an add-on for very high-risk secondary prevention patients. It's a valuable oral option when statins aren't tolerated.
Treat your cancer survivors to the same LDL targets
If a cancer survivor with prior MI needs a high-intensity statin and their oncologist hasn't initiated one, that's a gap you can close in primary care.
Consider inclisiran for PCSK9-intolerant or access-challenged patients
Twice-yearly injection given in-office removes the adherence barrier of self-injection. It's now guideline-endorsed for very high-risk patients who can't access or tolerate the mAbs.
Start statins in your HIV-positive patients 40–75
This is now a Class I recommendation. Review your HIV-positive panel and assess who is and isn't on statin therapy — drug interactions with antiretrovirals matter, but pravastatin and rosuvastatin are generally safer choices.
Don't recommend dietary supplements for cholesterol
The guideline explicitly says no (Class III). Armed with this, you can redirect patients toward dietary patterns (Mediterranean, DASH, plant-forward) and proven pharmacotherapy.
Use incidental CAC findings on any CT — they count now
If a chest CT PE protocol mentions coronary calcification, that's clinically actionable information for lipid management. Review those radiology reports actively.
Final ThoughtsFrom One NP to Another
The 2026 dyslipidemia guidelines are the most comprehensive, practically actionable cholesterol guidelines we've had in years. They give us clearer targets, better risk tools, and more validated therapies — including several that are genuinely new to this iteration.
What stands out most to me is the underlying philosophy: treat earlier, treat to goal, and individualize based on the whole patient — including their reproductive history, comorbidities, imaging, and genetic context. The days of "start a statin and recheck in a year" without a specific target in mind are over.
For those of us in primary care and telehealth, these guidelines validate what many of us have already been doing intuitively — and give us the evidence-based language to advocate for more aggressive therapy when our patients need it.
📄 Full Guideline Reference
Blumenthal RS, Morris PB, et al. 2026 ACC/AHA/AACVPR/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Dyslipidemia. J Am Coll Cardiol. 2026. DOI: 10.1016/j.jacc.2025.11.016. Available at acc.org and professional.heart.org.
Comments
Post a Comment