New ACC/AHA cholesterol guidelines promote earlier detection, personalized risk assessment, and more aggressive LDL cholesterol lowering to reduce long-term cardiovascular disease risk.
For decades, cholesterol management has been a cornerstone of heart disease prevention. Yet despite widespread awareness, cardiovascular disease remains the leading cause of death worldwide, and millions of adults continue to have cholesterol levels that put them at increased risk.
In response to evolving evidence, the American College of Cardiology and the American Heart Association have released updated clinical guidelines that place greater emphasis on earlier detection, more personalized risk assessment, and targeted treatment strategies.
Published jointly in the Journal of the American College of Cardiology and Circulation, the recommendations focus on lowering elevated levels of low-density lipoprotein (LDL) cholesterol, commonly known as “bad” cholesterol, as well as other blood lipids, including lipoprotein(a) (Lp(a)), a genetically influenced risk factor for heart disease.
The guideline also calls for earlier cholesterol screening, particularly for people with a family history of cardiovascular disease, and encourages clinicians to incorporate a broader range of health factors when evaluating a patient’s long-term risk and determining treatment options.
“We know that lower LDL cholesterol levels are better when it comes to reducing the risk of heart attacks, strokes and congestive heart failure,” says Roger S. Blumenthal, M.D., chair of the guideline writing committee and director of the Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease. “We also know that bringing elevated lipids and blood pressure down in young adults supports optimal heart and vascular health throughout a person’s life.”
Rising LDL Cholesterol Risks and Lifestyle Foundations
Studies show that about one in four U.S. adults has elevated LDL cholesterol (LDL-C), a major contributor to atherosclerosis (the narrowing or hardening of the arteries). Excess lipids can accumulate in artery walls and form plaque. As plaque builds, it can restrict blood flow. Factors such as aging and other cardiovascular risks can also increase the likelihood of plaque rupture, potentially leading to a heart attack, stroke, or emergency procedures to restore circulation.
Blumenthal notes that the core principles of heart-healthy living remain unchanged. These include following a healthy diet, exercising regularly, avoiding tobacco, getting adequate sleep, and maintaining a healthy weight. He points out that an estimated 80% to 90% of cardiovascular disease is linked, at least in part, to modifiable risk factors, making lifestyle changes the foundation of prevention.
One notable update is the recommendation to begin screening earlier and to place greater emphasis on factors such as family history of atherosclerosis, conditions like rheumatoid arthritis, and lifetime risk factors, including early menopause, preeclampsia, and gestational diabetes, when evaluating cardiovascular risk and treatment options.
For instance, people with familial hypercholesterolemia, an inherited condition that causes extremely high LDL-C levels, are now advised to begin screening in childhood, around age 9 or even earlier. The guideline also recommends a one-time Lp(a) test. Elevated Lp(a), which is often genetically determined, is associated with roughly a 40% higher risk of heart disease at levels of 125 nanomoles per liter and about double the risk at 250 nanomoles per liter.
PREVENT Risk Calculator Improves Personalized Assessment
Another major change is the adoption of a new tool for estimating both 10-year and 30-year risks of heart attack and stroke. The previous pooled cohort equation was designed to estimate 10-year cardiovascular risk in adults age 40 and older using factors such as age, cholesterol levels, and blood pressure.
The new calculator, known as Predicting Risk of Cardiovascular Disease EVENTs (PREVENT), incorporates additional measures, including blood sugar and kidney health indicators. It is recommended for use beginning at age 30. PREVENT was developed using data from 6.6 million people, compared with approximately 26,000 individuals used for the earlier calculator.
“Shifting the paradigm toward proactive prevention strategies earlier in life can meaningfully change the trajectory of cardiovascular disease and lead to better health outcomes for people decades later,” says Seth Martin, M.D., M.H.S., a cardiologist, member of the guideline writing committee and director of the Advanced Lipid Disorders Program and Digital Health Lab at the Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease.
To further personalize risk evaluation, the guideline offers recommendations for considering atherosclerosis “risk enhancers.”
Risk Enhancers and Coronary Calcium Screening
For people with borderline or intermediate risk, clinicians may use additional tests to guide treatment decisions. These can include measuring high-sensitivity C-reactive protein (hsCRP), a marker of inflammation in the bloodstream. Elevated Lp(a), a family history of early cardiovascular disease, and higher-risk ancestry may also influence risk assessments.
The guideline also expands recommendations for coronary artery calcium scans, which can identify calcium deposits within artery plaque and help tailor treatment plans.
Additional guidance is provided for pregnant or lactating women, adults age 75 and older, and people with conditions such as diabetes, advanced chronic kidney disease, HIV infection, or cancer.
The document includes updated recommendations on statin use as well as other cholesterol-lowering therapies, including ezetimibe, bempedoic acid, and injectable PCSK9 monoclonal antibodies. These treatments may be appropriate for people who do not achieve sufficient LDL-C reductions with statins alone or who require combination therapy.
Lower LDL Targets and Expanded Treatment Options
For individuals without cardiovascular disease, optimal LDL-C levels remain below 100 mg/dL. The guideline recommends lowering LDL-C to below 70 mg/dL for those at intermediate risk and below 55 mg/dL for people at higher risk. It also includes targets and recommendations for non-HDL-C and apolipoprotein B, a protein attached to cholesterol particles.
In an accompanying editorial, Blumenthal and the vice-chair of the 2026 ACC/AHA/Multisociety Dyslipidemia Guideline suggested that future recommendations may advise people with at least moderate atherosclerosis to target LDL-C levels below 55 mg/dL as well.
The 2026 guideline was finalized before the publication of the VESALIUS-CV clinical trial results in the New England Journal of Medicine. That study reported benefits from achieving these LDL-C targets through combinations of cholesterol-lowering therapies.
References:
“The ABCs of cardiovascular disease prevention: communicating what we know in 2026” by Lea R. Goren, Allison W. Peng, Alexander C. Razavi, Michael J. Blaha, Roger S. Blumenthal and Aaron L. Troy, 20 March 2026, American Journal of Preventive Cardiology.
DOI: 10.1016/j.ajpc.2026.101570
“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” by Roger S. Blumenthal, FACC, FAHA, FASPC, FNLA, Pamela B. Morris, FACC, FAHA, FASPC, FNLA, Mario Gaudino, FAHA, FACC, Heather M. Johnson, MS, FAHA, FACC, FASPC, Timothy S. Anderson, Vera A. Bittner, MSPH, FACC, FAHA, MNLA, MAACVPR, Ron Blankstein, FACC, LaPrincess C. Brewer, FACC, FAHA, Leslie Cho, FACC, Sarah D. de Ferranti, FAHA, Eugenia Gianos, FACC, FAHA, FNLA, Ty J. Gluckman, MHA, FACC, FAHA, FASPC, Kristen F. Gradney, MHA, RDN, LDN, Ijeoma Isiadinso, FACC, Donald M. Lloyd-Jones, ScM, FACC, FAHA, FASPC, Joel C. Marrs, PharmD, FAHA, FNLA, Seth S. Martin, MHS, FACC, FAHA, FASPC, Kellie H. McLain, ANP-BC, CLS, FNLA, AACC, Laxmi S. Mehta, FACC, FAHA, FNLA, Samia Mora, MHS, FACC, FAHA, Wudeneh M. Mulugeta, MS, FACP, FACPM, Pradeep Natarajan, MMSCFACC, FAHA, Ann Marie Navar, FAHA, FACC, FASPC, Carl E. Orringer, FACC, MNLA, Tamar S. Polonsky, MSCI, Harmony R. Reynolds, FACC, FAHA, Joseph J. Saseen, PharmD, MNLA, FACC, FAHA, Michael D. Shapiro, DO, FACC, FAHA, FASPC, FNLA, Daniel E. Soffer, MNLA, FACP, Sheila A. Tynes, MHA, PMP, Chloé D. Villavaso, MN, APRN, ACNS-BC, FPCNA, AACC, Salim S. Virani, FACC, FASPC and John T. Wilkins, MSc, FAHA, 13 March 2026, Journal of the American College of Cardiology.
DOI: 10.1016/j.jacc.2025.11.016
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