2026 AHA/ACC Cholesterol Guidelines

LDL Goal Based on PREVENT 10-Year ASCVD Risk

Category 10-Year ASCVD Risk Risk Group / LDL Goal
Low <3% No specific LDL goal
Borderline 3-<5% <100 mg/dL
Intermediate 5-<10% <100 mg/dL
High ≥10% <70 mg/dL
Extremely High Secondary prevention <55 mg/dL

PREVENT ASCVD Risk Calculator

10-year and 30-year PREVENT ASCVD estimates

Optional

PREVENT Equation

New PREVENT-ASCVD calculator replaces the Pooled Cohort Equation.

  • Age 30–79
  • LDL 70–189 mg/dL
  • No ASCVD or subclinical atherosclerosis

Coronary Artery Calcium

CAC scoring is now recommended for those in whom statin indication is uncertain.

  • Men ≥40
  • Women ≥45
  • Borderline or intermediate risk
    • Any scoring on the CAC necessitates an LDL goal < 100

Lipoprotein(a)

  • Measure once in adulthood for ALL patients
  • Genetically determined, stable overtime

Apolipoprotein B

  • Helps assess residual risk when LDL appears controlled
  • Reflects number of atherogenic particles
  • Most useful in: diabetes, hypertriglyceridemia, CKD, established ASCVD

Medications

  • Statins remain first-line therapy
  • If additional LDL lowering is needed
    • Ezetimibe
    • Bempedoic acid
    • PCSK9 inhibitors
    • Inclisiran in clinical trials

Special Populations

Consider lipid-lowering therapy starting around age 40 in:

  • CKD ≥3
  • HIV
  • T1DM
  • T2DM

Other points

  • Continue statins in most patients receiving cancer therapy
  • Defer most lipid-lowering medications during pregnancy, conception, and lactation
  • Universal cholesterol screening between ages 9–11

References

  1. Blumenthal, R. S., et al. (2026). 2026 ACC/AHA/AACVPR/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline for the management of dyslipidemia. Circulation. https://doi.org/10.1161/CIR.0000000000001423
  2. Khan, S. S., Matsushita, K., Sang, Y., Ballew, S. H., Grams, M. E., Surapaneni, A., Blaha, M. J., Carson, A. P., Chang, A. R., Coresh, J., Daya, N., Lee, C. J., Lloyd-Jones, D. M., Lutsey, P. L., Michos, E. D., Ndumele, C. E., Nambi, V., Selvin, E., Vasan, R. S., ... Karmali, K. N. (2023). Development and validation of the American Heart Association's PREVENT equations. Circulation, 148(24), 1982–2004. https://doi.org/10.1161/CIRCULATIONAHA.123.067626
  3. Cho, S. M. J., et al. (2025). AHA PREVENT equations and cardiovascular disease risk prediction across U.S. health care systems. Journal of the American College of Cardiology. https://doi.org/10.1016/j.jacc.2025.04.066
  4. Grundy, S. M., Stone, N. J., Bailey, A. L., Beam, C., Birtcher, K. K., Blumenthal, R. S., Braun, L. T., de Ferranti, S., Faiella-Tommasino, J., Forman, D. E., Goldberg, R., Heidenreich, P. A., Hlatky, M. A., Jones, D. W., Lloyd-Jones, D., Lopez-Pajares, N., Ndumele, C. E., Orringer, C. E., Peralta, C. A., ... Yeboah, J. (2019). 2018 AHA/ACC guideline on the management of blood cholesterol. Circulation, 139(25), e1082–e1143. https://doi.org/10.1161/CIR.0000000000000625
  5. O'Donoghue, M. L., Rosenson, R. S., Gencer, B., López, J. A. G., Lepor, N. E., Baum, S. J., Stout, E., Gaudet, D., Knusel, B., Kuder, J. F., Murphy, S. A., Wiviott, S. D., & Sabatine, M. S. (2022). Small interfering RNA to reduce lipoprotein(a) in cardiovascular disease. The New England Journal of Medicine, 387(20), 1855–1864. https://doi.org/10.1056/NEJMoa2211023
  6. Nissen, S. E., Lincoff, A. M., Brennan, D., Ray, K. K., Mason, D., Kastelein, J. J. P., Thompson, P. D., Libby, P., Cho, L., Plutzky, J., Bays, H. E., Moriarty, P. M., Menon, V., Grobbee, D. E., Louie, M. J., Chen, C. F., Li, N., Bloedon, L., Robinson, P., & Nicholls, S. J. (2023). Bempedoic acid and cardiovascular outcomes in statin-intolerant patients. The New England Journal of Medicine, 388(15), 1353–1364. https://doi.org/10.1056/NEJMoa2215024
  7. Sabatine, M. S., Giugliano, R. P., Keech, A. C., Honarpour, N., Wiviott, S. D., Murphy, S. A., Kuder, J. F., Wang, H., Liu, T., Wasserman, S. M., Sever, P. S., Pedersen, T. R., & FOURIER Steering Committee and Investigators. (2017). Evolocumab and clinical outcomes in patients with cardiovascular disease. The New England Journal of Medicine, 376(18), 1713–1722. https://doi.org/10.1056/NEJMoa1615664