2026 ACC/AHA Guideline on the Management of Dyslipidemia

Authors, Journal, Affiliations, Type, DOI

• Authors: Roger S. Blumenthal (Chair), Pamela B. Morris (Vice Chair), and 29 additional writing committee members
• Journal: Circulation, 2026;153
• Affiliations: ACC/AHA Joint Committee on Clinical Practice Guidelines; endorsed by AACVPR, ABC, ACPM, ADA, AGS, APhA, ASPC, NLA, PCNA
• Type: Clinical Practice Guideline
• DOI: 10.1161/CIR.0000000000001423

Overview

The 2026 ACC/AHA Guideline on the Management of Dyslipidemia retires and replaces the 2018 Guideline on Management of Blood Cholesterol. It expands scope to cover elevated LDL-C, hypertriglyceridemia, and elevated Lp(a). Major updates include adoption of the PREVENT-ASCVD equations for risk assessment (replacing Pooled Cohort Equations), reinstatement of absolute LDL-C and non-HDL-C treatment goals, universal Lp(a) measurement for all adults, and codification of ApoB as a therapeutic guidance marker. New medications (bempedoic acid, inclisiran, olezarsen) are incorporated based on cardiovascular outcomes trial data from FOURIER, ODYSSEY OUTCOMES, CLEAR OUTCOMES, and REDUCE-IT.

Keywords

AHA Scientific Statements · anticholesteremic agents · atherosclerosis · cardiovascular disease · cholesterol · dyslipidemia · HDL · hydroxymethylglutaryl-CoA reductase inhibitors · hypercholesterolemia · hypertriglyceridemia · LDL · lipoprotein(a) · primary prevention · risk assessment · statin · triglycerides

Key Takeaways

What Is New (Major Changes from 2018)

• PREVENT-ASCVD equations replace Pooled Cohort Equations (PCE) for 10- and 30-year risk estimation in adults aged 30–79. Risk estimates are 40–50% lower than PCE for the same risk profile
• Risk categories revised (PREVENT): low <3%, borderline 3–<5%, intermediate 5–<10%, high ≥10% (vs PCE: <5%, 5–<7.5%, 7.5–<20%, ≥20%)
• LDL-C and non-HDL-C treatment goals reinstated alongside percentage reduction targets
• Lp(a) universal measurement: COR 1 recommendation for at least one lifetime measurement in all adults
• ApoB measurement: New COR 2a recommendation to guide intensification once LDL-C/non-HDL-C goals met
• CAC scoring upgraded: Multiple new COR 1 recommendations for CAC-guided treatment goals in subclinical atherosclerosis
• Dietary supplements: New COR 3 (No Benefit) — not recommended to lower LDL-C or TG
• Bempedoic acid: New COR 1/2a recommendations for secondary and high-risk primary prevention with statin intolerance
• Inclisiran (siRNA PCSK9i): New COR 2a options for secondary prevention
• Olezarsen (apoC3 ASO): COR 1 for familial chylomicronemia syndrome (FCS)
• Martin/Hopkins and Sampson/NIH equations preferred over Friedewald for LDL-C estimation (upgraded from COR 2a → COR 1)

Screening and Evaluation

• Lipid profile screening recommended from age 19 every ≥5 years in adults; universal screening in children ages 9–11 (COR 1)
• Cascade screening with single lipid profile from age ≥2 if family history of premature ASCVD or FH (COR 2a)
• Fasting profile preferred when TG ≥400 mg/dL, family history of dyslipidemia, or known TG metabolism disorder
• Non-HDL-C should be routinely reported alongside LDL-C (COR 1)
• Advanced lipoprotein testing (NMR, gel electrophoresis) not recommended for routine use (COR 3: No Benefit)

ApoB Measurement

• In adults on LLT with ASCVD, CKM syndrome, type 2 diabetes, and/or elevated TG: measure ApoB to guide intensification once LDL-C/non-HDL-C goals met (COR 2a)
• In adults not on LLT: ApoB may enhance risk assessment (COR 2b)
• ApoB predicts ASCVD risk more accurately than LDL-C in cases of discordance; most common in cardiometabolic disease, elevated TG ≥150 mg/dL
• Martin/Hopkins method markedly reduces LDL-C/ApoB discordance vs Friedewald; only ~2% with LDL-C <70 mg/dL by Martin/Hopkins had ApoB exceeding guideline targets

Lp(a) Measurement

• Measure at least once in all adults for ASCVD risk assessment (COR 1)
• Cascade testing of first-degree family members if FH, premature ASCVD, or high Lp(a) (COR 1)
• Use isoform-insensitive assays calibrated to official reference standards (COR 1)
• Risk thresholds: ≥125 nmol/L (50 mg/dL) = ~1.4× risk; ≥250 nmol/L (100 mg/dL) = ~2× risk; ≥350 nmol/L = ~3× risk; ≥430 nmol/L = ~4× risk (equivalent to HeFH)
• Single measurement generally sufficient; Lp(a) is 80–90% genetically determined

ASCVD Risk Assessment (PREVENT Equations)

• PREVENT-ASCVD derived in ~3.3 million contemporary US adults; validated in separate ~3.3 million
• Variables: age, sex, blood pressure, total/HDL-C, diabetes, tobacco, eGFR, statin use, antihypertensive medication; optional: HbA1c, urine albumin/creatinine ratio, zip code (social deprivation index)
• Race/ethnicity NOT included (did not add predictive value)
• Provides 10-year and 30-year estimates; predicts hard ASCVD, HF, and total CVD
• CPR Framework: Calculate 10-year risk → Personalize with risk enhancers/reproductive markers → Reclassify with CAC if uncertain

Risk Enhancers (Table 13)

• Family history of premature ASCVD (men <55, women <65)
• Higher-risk ancestry (South Asian, Filipino)
• Chronic inflammatory diseases (SLE, RA, psoriasis)
• Lp(a) ≥125 nmol/L or ≥50 mg/dL
• hsCRP ≥2 mg/L on >1 occasion
• TG persistently ≥175 mg/dL (nonfasting) or ≥150 mg/dL (fasting)
• CKM syndrome
• LDL-C persistently 160–189 mg/dL, non-HDL-C ≥190–219 mg/dL, or ApoB ≥120 mg/dL
• Reproductive risk markers (premature menopause <45 y, preeclampsia, gestational diabetes, gestational hypertension, preterm delivery)
• hsCRP ≥2 mg/L on 2 successive occasions (no identifiable cause) → high-intensity statin useful even at borderline risk (COR 2a)

Primary Prevention Treatment Goals

CAC Score-Guided Management (Men ≥40, Women ≥45 y)

• CAC = 0 AU + no higher-risk conditions → defer therapy, reassess in 3–7 years (COR 2a)
• CAC 1–99 AU or <75th percentile → moderate-intensity statin, LDL-C <100 mg/dL (COR 2a)
• CAC 100–299 AU or ≥75th percentile → statin, LDL-C <70 mg/dL (COR 1)
• CAC 300–999 AU → statin, LDL-C <70 mg/dL; consider intensification to LDL-C <55 mg/dL (COR 1/2a)
• CAC ≥1000 AU → LDL-C <55 mg/dL, non-HDL-C <85 mg/dL (COR 1)
• Incidental CAC on non-cardiac CT → should inform LLT decision (COR 1)

Secondary Prevention

• Not very high risk: High-intensity statin → LDL-C <70 mg/dL + non-HDL-C <100 mg/dL; add ezetimibe/PCSK9 mAb/bempedoic acid to reach <55 mg/dL (COR 2a)
• Very high risk (≥2 major ASCVD events OR 1 event + ≥2 high-risk features): LDL-C <55 mg/dL + non-HDL-C <85 mg/dL; add ezetimibe AND/OR PCSK9 mAb (COR 2a); bempedoic acid and inclisiran also options

Severe Hypercholesterolemia (LDL-C ≥190 mg/dL)

• Standard risk calculators (PREVENT) should NOT be used in HeFH (COR 3)
• No clinical ASCVD, no HeFH, no additional risk factors: maximally tolerated statin + ezetimibe/PCSK9 mAb/bempedoic acid → LDL-C <100 mg/dL (COR 1)
• HeFH or additional risk factors/coronary calcification: LDL-C <70 mg/dL (COR 1)
• With clinical ASCVD: LDL-C <55 mg/dL (COR 1)
• Genetic panel testing for FH pathogenic variants useful in severe hypercholesterolemia (COR 2a)
• HoFH with LDL-C ≥100 mg/dL on max statin + ezetimibe + PCSK9 mAb: consider evinacumab (COR 2b)

Diabetes (Without ASCVD, Age 40–75)

• Moderate-intensity statin: LDL-C <100 mg/dL + ≥30–49% reduction (COR 1)
• Multiple ASCVD risk factors: high-intensity statin: LDL-C <70 mg/dL + ≥50% reduction (COR 2a)

Special Populations

• CKD Stage 3+: Statin ± ezetimibe ± PCSK9 mAb for ASCVD (COR 1 for ASCVD + CKD ≥3); statins NOT beneficial in dialysis (2 large RCTs negative)
• HIV (age 40–75, stable ART): Pitavastatin COR 1 (REPRIEVE: 35% MACE reduction); pitavastatin preferred — minimal CYP3A4 metabolism reduces DDI
• Cancer survivors (life expectancy ≥2 y): Treat as if no cancer history (COR 1); continue statins in active cancer unless DDI or life expectancy <1 y (COR 1)
• Pregnancy with TG ≥500 mg/dL: Fibrates (after first trimester) or high-dose omega-3 ethyl esters reasonable (COR 2a)
• Age >75: LDL-C-lowering pharmacotherapy can be considered (individualized decision)

Hypertriglyceridemia Management

• Lifestyle first for TG ≥150 mg/dL: low added sugar/refined carbs/saturated fat; no alcohol; weight loss 5–10%; exercise ≥150 min/wk
• TG 150–999 mg/dL + clinical ASCVD + LDL-C ≥55 mg/dL: intensify LDL-C lowering (COR 1)
• FCS + TG ≥1000 mg/dL: olezarsen (apoC3 ASO) COR 1 (BALANCE trial: −43.5% TG, fewer pancreatitis episodes)
• TG ≥500 mg/dL despite diet: fibrates or prescription omega-3 fatty acids reasonable (COR 2a); gemfibrozil MUST NOT be combined with statins
• Icosapent ethyl (IPE): COR 2b for age ≥50 with ASCVD or diabetes + ≥1 risk factor + TG 150–499 mg/dL + LDL-C <100 mg/dL (REDUCE-IT: 25% composite reduction; caveats about mineral oil placebo and AF risk)
• Non-HDL-C or ApoB preferred over LDL-C in hypertriglyceridemia (COR 2a)

Elevated Lp(a) Management

• Optimize modifiable cardiovascular risk factors (COR 1)
• In ASCVD + elevated Lp(a) not at LDL-C/non-HDL-C goals on max statin: add PCSK9 mAb (COR 1)
• PCSK9 mAbs reduce Lp(a) ~15–30%; not FDA-approved specifically for Lp(a) lowering
• Specific Lp(a)-lowering RNA therapies (mRNA, small-molecule oral inhibitors) in phase 3 CVOTs
• Statins do not lower Lp(a) (may modestly increase by mean ~1.1 mg/dL — not clinically significant)

Statin-Attributed Muscle Symptoms (SAMS)

• Assess secondary causes; measure CK only for severe symptoms (COR 1)
• Acknowledge patient concerns; inform of ASCVD risk with discontinuation (COR 1)
• Established ASCVD + SAMS: reduced statin dose + bempedoic acid, ezetimibe, and/or PCSK9 mAb (COR 1)
• High-risk primary prevention + SAMS: bempedoic acid ± ezetimibe (COR 1); add PCSK9 mAb if goals not met (COR 1)
• CoQ10 NOT recommended for SAMS prevention/treatment (COR 3: No Benefit)
• Routine CK measurement and hepatic transaminase monitoring NOT recommended during statin therapy (COR 3: No Benefit)

Medication Classes Summary

Dietary Supplements

• Fish oil, red yeast rice, berberine, garlic, cinnamon, turmeric, plant sterols: no significant LDL-C reduction vs placebo in SPORT trial
• COR 3: No Benefit — dietary supplements not recommended to lower LDL-C or TG

Limitations of the Document

• Literature search cut-off October–December 2024 (select studies to April 2025); rapidly evolving field
• CVOTs are population-level; individual net benefit varies; absolute thresholds require individualization
• PREVENT-ASCVD equations derived in US adults; generalizability to non-US populations uncertain
• REDUCE-IT mineral oil placebo controversy limits confidence in IPE cardiovascular benefit magnitude
• Lp(a)-specific lowering therapies still in phase 3 trials; no definitive CVOT data yet
• Limited RCT data in adults >75, age 18–29, and specific ethnic subgroups
• Polygenic risk scores not yet ready for routine clinical use (methodological heterogeneity, validation gaps)
• Economic value statements not included due to rapidly evolving drug pricing

Key Concepts Mentioned

• concepts/Dyslipidemia-Management — core topic; entire guideline addresses evaluation and treatment
• concepts/ASCVD-Risk-Assessment — PREVENT equations, CPR framework, CAC scoring
• concepts/Lipoprotein-a — universal measurement recommendation, risk quantification, management
• concepts/Familial-Hypercholesterolemia — special management track for LDL-C ≥190 mg/dL

Key Entities Mentioned

• entities/Heart-Failure — statin consideration in HFrEF; HF as high-risk feature in secondary prevention
• entities/Atrial-Fibrillation — IPE-associated AF risk; fish oil supplement AF risk

Wiki Pages Updated

• wiki/sources/lipid-aha-2026.md — created (this file)
• wiki/concepts/Dyslipidemia-Management.md — created
• wiki/concepts/ASCVD-Risk-Assessment.md — created
• wiki/concepts/Lipoprotein-a.md — created
• wiki/concepts/Familial-Hypercholesterolemia.md — created
• wiki/sourceindex.md — updated
• wiki/wikiindex.md — updated
• log.md — updated