Summary

The 2026 ACC/AHA dyslipidemia guideline replaces the 2018 cholesterol guideline and broadens scope to include hypertriglyceridemia and elevated Lp(a). Major changes include adoption of the PREVENT-ASCVD risk equations (replacing the Pooled Cohort Equations) with lower treatment thresholds, reinstatement of explicit LDL-C and non–HDL-C goals, universal once-in-a-lifetime Lp(a) measurement, expanded role for apoB testing, and incorporation of newer agents (bempedoic acid, inclisiran, evinacumab, olezarsen) alongside statins, ezetimibe, and PCSK9 mAbs. The guideline emphasizes the “CPR” framework (Calculate–Personalize–Reclassify with CAC) and earlier intervention to reduce lifetime atherogenic lipoprotein exposure.

Key Recommendations

Use PREVENT-ASCVD equations (not Pooled Cohort Equations) to estimate 10-year ASCVD risk in adults 30–79 years, categorizing as low (<3%), borderline (3–<5%), intermediate (5–<10%), or high (≥10%).
Use the Martin/Hopkins or Sampson/NIH equation in preference to Friedewald for LDL-C estimation in all adults and children.
Measure Lp(a) at least once in every adult for ASCVD risk assessment; ≥125 nmol/L (50 mg/dL) is a risk-enhancer and ≥250 nmol/L (100 mg/dL) approximately doubles ASCVD risk.
Measure apoB in adults on LLT—particularly those with ASCVD, CKM syndrome, type 2 diabetes, or elevated TG—to guide intensification after LDL-C/non–HDL-C goals are met.
In secondary prevention at very high risk, initiate high-intensity statin to achieve ≥50% LDL-C reduction with goal LDL-C <55 mg/dL and non–HDL-C <85 mg/dL; add ezetimibe and/or a PCSK9 mAb (and optionally bempedoic acid or inclisiran) if goal not met.
In secondary prevention not at very high risk, target LDL-C <70 mg/dL and non–HDL-C <100 mg/dL with high-intensity statin, adding ezetimibe, PCSK9 mAb, or bempedoic acid as needed.
In primary prevention adults 40–75 years with diabetes, CKD stage ≥3, or HIV, initiate statin therapy regardless of LDL-C; use high-intensity statin if multiple risk factors with goal LDL-C <70 mg/dL.
In adults with LDL-C ≥190 mg/dL, exclude secondary causes, start maximally tolerated statin, and add ezetimibe, PCSK9 mAb, and/or bempedoic acid; goal LDL-C <55 mg/dL if clinical ASCVD, <70 mg/dL with HeFH or other risk factors, otherwise <100 mg/dL.
In intermediate- or selected borderline-risk adults with uncertain LLT decisions, obtain CAC score: if 0 AU defer therapy and repeat in 3–7 years; if ≥100 AU or ≥75th percentile initiate LLT; if ≥300 AU treat as high risk.
For familial chylomicronemia syndrome with TG ≥1000 mg/dL, prescribe olezarsen (apoC3 inhibitor) plus very-low-fat diet to lower TG and reduce pancreatitis risk.
In ASCVD patients with TG 150–499 mg/dL and LDL-C <100 mg/dL on statin, icosapent ethyl is reasonable for additional ASCVD risk reduction; do not use niacin or fibrates as add-on to statin for ASCVD prevention.
Discontinue statins 1–2 months before planned pregnancy in low-risk patients, but consider continuing in HeFH or ASCVD; lipoprotein apheresis is reasonable for HoFH during pregnancy/lactation.
Recheck lipid profile 4–12 weeks after initiating or adjusting LLT, then every 6–12 months; routine CK and LFT monitoring are not indicated absent symptoms.

Thresholds & Doses

Lipid screening: adults beginning age 19 years, every 5 years; children once at age 9–11 years.
Lp(a) elevated ≥125 nmol/L (50 mg/dL) → ~1.4× ASCVD risk; ≥250 nmol/L (100 mg/dL) → ~2×; ≥430 nmol/L (180 mg/dL) → ~4×.
PREVENT 10-year ASCVD risk categories: low <3%, borderline 3–<5%, intermediate 5–<10%, high ≥10%.
Primary prevention LDL-C goals: borderline/intermediate risk LDL-C <100 and non–HDL-C <130 mg/dL; high risk LDL-C <70 and non–HDL-C <100 mg/dL.
Secondary prevention LDL-C goal: <70 mg/dL (non–HDL-C <100) if not very high risk; <55 mg/dL (non–HDL-C <85) if very high risk or CKD.
HeFH/severe hypercholesterolemia goal LDL-C <70 mg/dL if extra risk factors; <55 mg/dL with clinical ASCVD.
Severe hypercholesterolemia defined as LDL-C ≥190 mg/dL, non–HDL-C ≥220 mg/dL, and/or apoB ≥140 mg/dL.
CAC management thresholds: 1–99 AU and <75th %ile → moderate-intensity statin (LDL-C <100); 100–299 AU or ≥75th %ile → ≥50% LDL-C reduction, goal <70; 300–999 AU → goal <70; ≥1000 AU → goal <55 mg/dL.
Diabetes primary prevention age 40–75: moderate-intensity statin for ≥30–49% LDL-C reduction; high-intensity statin if multiple risk factors for ≥50% reduction.
High-intensity statin doses: atorvastatin 40–80 mg, rosuvastatin 20–40 mg (≥50% LDL-C reduction).
Moderate-intensity statin: atorvastatin 10–20 mg, rosuvastatin 5–10 mg, simvastatin 20–40 mg, pravastatin 40–80 mg, lovastatin 40 mg, fluvastatin XL 80 mg, pitavastatin 1–4 mg (30–49% reduction).
Ezetimibe 10 mg daily (~18% LDL-C reduction monotherapy; +25% added to statin).
PCSK9 mAb: alirocumab 75–150 mg SC q2 weeks; evolocumab 140 mg SC q2 weeks (45–64% LDL-C reduction).
Inclisiran 284 mg SC at day 0, day 90, then every 6 months (48–52% LDL-C reduction).
Bempedoic acid 180 mg PO daily (~17–24% LDL-C reduction).
Icosapent ethyl 2 g PO twice daily with food for TG 150–499 mg/dL with ASCVD or diabetes + risk factor.
Olezarsen 80 mg SC monthly for FCS (~30–43% TG reduction).
Evinacumab 15 mg/kg IV every 4 weeks for HoFH (~49% LDL-C reduction).
Hypertriglyceridemia categories: ≥150 mg/dL (1.7 mmol/L) moderate; ≥500 mg/dL (5.7 mmol/L) severe; ≥1000 mg/dL (11.3 mmol/L) very severe / pancreatitis risk.
Friedewald inaccurate when TG ≥400 mg/dL; cannot be calculated.
Weight loss goal 5–10% of body weight for overweight/obese with elevated TG; physical activity ≥150 min/wk moderate-intensity plus resistance exercise 2 d/wk.
hsCRP ≥2 mg/L on 2 occasions in borderline-risk adults supports high-intensity statin.
Older adults: consider statin if life expectancy ≥2.5 years; discontinue if <1 year.
Reproductive risk markers: early menopause <45 years, premature menopause <40 years; early menarche <10 years.

Citations

Top Take-Home Messages — overview of major changes including PREVENT equations, Lp(a), apoB, CAC, and LDL-C goals.
Table 1 (What Is New) — section-by-section comparison of 2018 vs 2026 recommendations.
Section 3.4 / Table 4 — Lp(a) measurement once in all adults and risk stratification by concentration.
Section 4.2.3.2 / Tables 11–12 — PREVENT-ASCVD equations and crosswalk to PCE risk categories.
Section 4.2.3.6 — CAC scoring thresholds (0, 1–99, 100–299, 300–999, ≥1000 AU) and management.
Section 4.2.4.3 / Figure 7 — Management of severe hypercholesterolemia (LDL-C ≥190 mg/dL) with tiered LDL-C goals.
Section 4.2.6 / Figures 10–11 — Secondary prevention recommendations and very-high-risk criteria with LDL-C <55 mg/dL goal.
Section 4.2.9 / Figures 14–17 / Table 23 — Management of hypertriglyceridemia including olezarsen for FCS and IPE indications.
Table 5 — Characteristics and dosing of lipid-lowering medications.
Section 5.1 / Tables 25–26 — Medication safety, side effects, and contraindications.
Section 5.2 / Table 27 — Statin–cardiovascular drug interactions.