| Blumenthal RS et al. | Circulation 2026 | American College of Cardiology / American Heart Association Updated guideline replacing the 2018 Guideline — 123 pages, endorsed by 30+ clinical societies |
| 📅 Publication Date: March 2026 | 🏥 Replaces: 2018 Guideline | ✅ Endorsed By: 11 Medical Societies |
⚠️ Important Note:
This document is a public information tool. Always consult your physician for personal health decisions. The guideline is prepared to support the shared decision-making process between the physician and the patient.
A. Why is this Guideline Important?
Globally, cardiovascular diseases (heart and blood vessel diseases) remain the leading cause of death. High cholesterol is one of the most important and modifiable causes of this risk. The American College of Cardiology (ACC) and the American Heart Association (AHA) evaluated the latest scientific evidence and published the new cholesterol management guideline in 2026.
Why was the guideline updated?
- New drugs have gained clinical evidence since the 2018 guideline (bempedoic acid, PCSK9 inhibitors)
- More accurate risk calculation methods have been developed (PREVENT equations)
- The importance of new biomarkers such as Lipoprotein(a) and ApoB has been proven
- LDL target values were removed in 2018 — they have returned in 2026
- Very strong new evidence has emerged regarding the importance of early treatment
- The protective effect of bempedoic acid has been demonstrated in patients who cannot take statins
B. Basic Concepts: Cholesterol and Blood Fats
B.1 What is Cholesterol?
Cholesterol is a fat that our body needs to build cell membranes, produce hormones, and aid in digestion. It is produced by the liver and is also absorbed from the animal-based foods we eat. The problem starts when too much of it accumulates in the blood.
| Cholesterol Type | Common Name | Function | Risk when High |
|---|---|---|---|
| LDL-C (Low Density) | ‘Bad’ Cholesterol | Transports cholesterol from the liver to tissues | Accumulates in the vessel wall, leading to blockages (atherosclerosis) |
| HDL-C (High Density) | ‘Good’ Cholesterol | Transports excess cholesterol from tissues back to the liver | Risk increases if low; protective if high |
| Triglycerides | Blood Fat | The body’s energy reserve; comes from food | If very high, risk of pancreas inflammation and heart disease |
| Non-HDL Cholesterol | Total Atherogenic Load | Sum of LDL + VLDL + IDL | Reflects the total burden of bad cholesterol |
| Lipoprotein(a) — Lp(a) | Genetic Risk Factor | LDL-like structure; genetically determined | Elevation is an independent heart attack risk factor |
| ApolipoproteinB — ApoB | Particle Count | Shows the number of all atherogenic lipoprotein particles | Reveals risks that might otherwise remain hidden |
B.2 Atherosclerosis: The Process of Clogged Arteries
LDL cholesterol sticks to the inner wall of blood vessels and forms plaque over time. This process begins in childhood and progresses silently for decades. When the plaque grows, it either narrows the artery or ruptures, causing sudden blockage (heart attack, stroke).
❤️ Important Fact: The effect of LDL cholesterol on atherosclerosis is cumulative and time-dependent. High LDL starting at an early age causes much more damage than the same level starting in middle age. Therefore, the 2026 guideline particularly emphasizes early treatment.
C. 10 Major Innovations of the 2026 Guideline
This guideline contains radical changes compared to 2018. Here are the 10 most important innovations:
INNOVATION 1: LDL Target Values Have Returned
In the 2018 guideline, the LDL target was removed, and only a ‘percentage reduction’ was recommended. The 2026 guideline recommends both percentage reduction and absolute target values together.
| Risk Group | LDL Target | Non-HDL Target |
|---|---|---|
| Very High-Risk ASCVD | < 55 mg/dL (1.4 mmol/L) | < 85 mg/dL (2.2 mmol/L) |
| High-Risk ASCVD (excluding Very High Risk) | < 70 mg/dL (1.8 mmol/L) | < 100 mg/dL (2.6 mmol/L) |
| Primary Prevention — High Risk | < 100 mg/dL or ≥50% reduction | < 130 mg/dL |
| Diabetes/CKD/HIV (40-75 years) | Medication recommended; target is individualized | — |
INNOVATION 2: New Risk Calculation — PREVENT Equations
The new ‘PREVENT Equations’ are now used instead of the old ‘Pooled Cohort Equations’. This new system can calculate both 10-year and 30-year risk.
CPR Model — Risk Assessment in Three Steps:
- C — Calculate: Calculate the 10-year risk using PREVENT-ASCVD equations
- P — Personalize: Consider risk enhancers (see table)
- R — Reclassify: Clarify the risk with a CAC score if necessary
| Risk Category | 10-Year Risk | Meaning |
|---|---|---|
| Low | < 3% | Medication is rarely recommended; lifestyle is the priority |
| Borderline | 3% – < 5% | Treatment may be considered if risk enhancers are present |
| Intermediate | 5% – < 10% | Treatment should be initiated through physician-patient discussion |
| High | ≥ 10% | Medication is generally recommended |
INNOVATION 3: Lp(a) Measurement is Now Recommended for Everyone
The 2026 guideline states as a Class 1 (highest) recommendation that all adults should have their Lp(a) [Lipoprotein(a)] measured at least once in their lifetime.
Why is Lp(a) Important?
- Lp(a) levels are primarily genetically determined and do not change
- Lifestyle changes have very little effect on Lp(a)
- A single measurement is usually sufficient
| Lp(a) Level | Meaning | Heart Disease Risk Increase |
|---|---|---|
| < 75 nmol/L (< 30 mg/dL) | Normal — reference | — |
| 75-124 nmol/L (30-49 mg/dL) | Mildly elevated | ≈ 1.2-fold increase |
| ≥ 125 nmol/L (≥ 50 mg/dL) | High — risk enhancer | ≈ 1.4-fold increase |
| ≥ 250 nmol/L (≥ 100 mg/dL) | Very high | ≈ 2-fold increase |
| ≥ 430 nmol/L (≥ 180 mg/dL) | Extremely high | ≈ 4-fold increase (similar to FH) |
🧬 Genetic Risk: High Lp(a) is passed down to children. If you or your first-degree relatives have high Lp(a), it is recommended that all first-degree family members (parents, siblings, children) get tested.
INNOVATION 4: ApoB Test — To Find Hidden Risk
The new guideline states that after LDL and non-HDL targets are reached, the ApoB test is useful for additional risk assessment. It is especially valuable in the following situations:
- People with elevated triglycerides (> 200 mg/dL)
- In patients with diabetes
- Those who continue to have risk concerns despite having achieved low LDL (< 70 mg/dL)
🔬 Why is ApoB Important? Standard cholesterol measurements can sometimes hide the risk. Even if LDL appears ‘normal’, ApoB can be high. ApoB counts all the harmful lipoprotein particles circulating in the blood and more accurately reflects the true danger.
INNOVATION 5: Coronary Artery Calcium (CAC) Score — A Determinant in Treatment Decisions
In some individuals, it may be uncertain whether to start medication. In these cases, the coronary artery calcium (CAC) score helps clarify the decision by measuring plaque accumulation in the heart arteries.
| Who Should Use It? | CAC = 0 | CAC > 0 |
|---|---|---|
| Intermediate-risk adults (men ≥40, women ≥45 years) | It may be reasonable to delay treatment* | Initiate medication |
| Borderline risk, individuals with uncertainty | Delay treatment for 3-7 years and re-evaluate* | Initiate treatment based on age and score |
| High risk (CAC≥100 or ≥75th percentile) | — | Initiate high-intensity medication |
*Exceptions: In those with familial hypercholesterolemia, LDL≥190, diabetes and over age 40, active smoking, or a family history of premature heart disease, even a CAC=0 is not enough to delay treatment.
INNOVATION 6: Early Treatment — Starting in Youth is Critical
The 2026 guideline presents strong evidence that bringing cholesterol management to earlier ages is life-saving.
- Preventing dyslipidemia with a healthy diet and exercise in childhood is the core strategy
- Early medication for children with genetic (familial) hypercholesterolemia
- Early initiation of medication in young adults if LDL ≥ 160 mg/dL or if there is a family history of premature heart disease
- Early and prolonged elevation of LDL causes much more damage than a short-term elevation
👶 Why is it so important to start early? The damage LDL does to the vessel wall accumulates over time. Someone living with high LDL from their 20s to their 60s is not in the same situation as someone whose high LDL started at age 40. Early prevention = less damage.
INNOVATION 7: Cholesterol Treatment in Diabetes, Chronic Kidney Disease, and HIV
For people aged 40-75 with diabetes, chronic kidney disease (stages 3-4), or HIV infection, cholesterol-lowering medication is recommended regardless of their LDL level.
| Condition | Recommendation | Rationale |
|---|---|---|
| Diabetes (40-75 years) | Medication regardless of LDL level | Diabetes itself is a high cardiovascular risk factor |
| Chronic Kidney Disease Stages 3-4 (40-75 years) | Medication regardless of LDL level | CKD significantly increases cardiovascular risk |
| HIV Infection (40-75 years) | Medication regardless of LDL level | HIV medications and chronic inflammation increase risk |
| Over 75 years | Lifestyle + individualized assessment | The balance of benefit and harm in older age must be considered |
INNOVATION 8: Ezetimibe Prerequisite for PCSK9 Inhibitors Removed
In the 2018 guideline, it was mandatory to use ezetimibe before switching to PCSK9 inhibitors (evolocumab, alirocumab). The 2026 guideline has removed this requirement. New Approach:
- Drug selection after statin therapy is now based on ‘how much LDL needs to be lowered?’ and ‘patient preference’
- The choice between ezetimibe, bempedoic acid, or a PCSK9 inhibitor is left to the clinician and the patient
- Long-term safety data for PCSK9 inhibitors has strengthened; the cost has also decreased
💊 Bempedoic Acid: A New Option for Those Who Cannot Take Statins
Bempedoic acid is a new hope for people who cannot take statins due to muscle pain. In the CLEAR Outcomes trial, it lowered LDL by 20% and significantly reduced the risk of heart attacks. Because it is not activated in muscle tissue, it does not cause statin-like side effects.
INNOVATION 9: A Clear ‘No’ to Dietary Supplements
The 2026 guideline explicitly opposes the use of dietary supplements to lower cholesterol or triglycerides. This is a Class 3 recommendation level — meaning ‘do not do it, it may cause harm or has no benefit’.
- Garlic capsules, red yeast rice, fish oil pills (not prescription high-dose omega-3), plant sterols, etc.
- The efficacy of these products in lowering LDL or triglycerides was found to be inconsistent and limited in clinical trials
- Using dietary supplements can lead to risk by delaying real treatment
⚠️ Beware of cholesterol supplements sold in pharmacies or online!
Supplements claiming to ‘lower cholesterol’ lack sufficient scientific evidence. They cannot replace real treatment. Do not use them without talking to your physician.
INNOVATION 10: Female-Specific Risk Factors Are Now Official
The 2026 guideline recommends that female-specific reproductive health history be included in the cardiovascular risk assessment.
Risk-Enhancing Women’s Health Factors:
- Premature menopause (before age 45)
- Hypertension during pregnancy (preeclampsia, gestational hypertension)
- Gestational diabetes
- Premature birth (before 37 weeks)
- Recurrent pregnancy loss
- Early menarche (before age 10)
In the presence of these factors, a woman’s risk of heart disease may be evaluated higher than it otherwise would be, and cholesterol-lowering treatment may be considered earlier.
D. Lifestyle — The Foundation of Treatment
Alongside any drug treatment, or even if medication is not required, lifestyle changes form the foundation of cholesterol management. The 2026 guideline states that lifestyle alone can reduce cardiovascular risk by approximately 50%.
D.1 Heart-Healthy Diet
| Recommended | Limit | Avoid |
|---|---|---|
| Olive oil, avocado (monounsaturated fat) | Red meat (1-2 servings per week) | Trans fats (partially hydrogenated vegetable oil) |
| Fatty fish (salmon, mackerel, tuna — 2x per week) | Full-fat dairy products (limited) | Processed meat products (salami, sausage, hot dogs) |
| High-fiber grains (oats, whole wheat bread) | Coconut oil, palm oil | Sugary drinks, pre-packaged fruit juice |
| Legumes (lentils, chickpeas, beans) | Egg yolks (3-4 per week is acceptable) | Ultra-processed foods, fast food |
| Plenty of vegetables and fruits (5 servings a day) | Salt restriction | Alcohol — raises triglycerides |
| Hazelnuts, walnuts, almonds (small portion) | White flour foods (pasta, white rice) | — |
D.2 Physical Activity AHA Recommendation — How Much Per Week?
- Moderate-intensity aerobic activity: At least 150 minutes per week (30 min a day, 5 days)
- Or: Vigorous-intensity aerobic activity: 75 minutes per week
- Muscle strengthening: 2 days a week
- Walk for 5 minutes every hour to reduce the harms of prolonged sitting
Effect of Exercise on Cholesterol:
- Lowers LDL by 5-10%
- Increases HDL
- Significantly lowers triglycerides
- Contributes to weight loss — weight loss lowers LDL even further
D.3 Other Lifestyle Recommendations
| Factor | Effect on Cholesterol | Our Recommendation |
|---|---|---|
| Smoking | Increases LDL, lowers HDL, directly damages vessels | Quit absolutely — the most effective cardiovascular preventive measure |
| Weight Management | Losing 5-10 kg lowers LDL by 10-15% | Maintain a healthy body mass index (18.5-24.9) |
| Stress Management | Chronic stress increases cortisol; negatively affects LDL | Meditation, sleep quality, social connections |
| Sleep | Short sleep and sleep apnea contribute to dyslipidemia | Aim for 7-9 hours of quality sleep |
| Alcohol | Significantly raises triglycerides |
E. Drug Treatments — Current Options
The choice of cholesterol-lowering medication is individualized by the physician, taking into account the person’s risk level, other diseases, tolerability, and preferences. Current options are summarized below.
| Drug Class | How it Works? | LDL Reduction | For Whom? | Side Effects |
|---|---|---|---|---|
| Statins(atorvastatin, rosuvastatin, etc.) | Reduces cholesterol production in the liver | 20-55% (depending on intensity) | First-line; for everyone | Muscle pain (rare); liver tests are monitored |
| Ezetimibe | Reduces cholesterol absorption from the intestines | 15-20% (25% when added to a statin) | Added when statins are insufficient | Generally well-tolerated |
| Bempedoic Acid | Blocks cholesterol synthesis in the liver via a different pathway | 20% alone; 38% with ezetimibe | For those unable to take statins | Gout (uric acid increase); joint pain |
| PCSK9 Inhibitors(evolocumab, alirocumab) | Increases LDL clearance by freeing LDL receptors | 50-60% | For those unable to reach target LDL | Injection site reaction; expensive |
| Inclisiran | Silences PCSK9 mRNA; long-acting injection | 50% (1 injection every 6 months) | For those intolerant to PCSK9 mAbs or seeking infrequent dosing | 2 cardiovascular outcome trials are not yet complete |
| Prescription Omega-3(icosapent ethyl) | Reduces triglyceride production in the liver | LDL effect is limited; lowers triglycerides by 20-30% | High triglycerides (≥ 500 mg/dL) | Fishy taste; atrial fibrillation risk |
| Fibrates(fenofibrate, etc.) | Strongly lowers triglycerides; increases HDL | Minimal LDL effect | Severe hypertriglyceridemia | Muscle enzyme; liver; kidney monitoring |
💊 If You Are Experiencing Statin Side Effects: If you cannot use statins due to muscle pain or liver problems, alternatives like bempedoic acid are now available. Talk to your physician; look for an alternative instead of stopping treatment. Stopping medication can increase your risk.
F. High Triglycerides — A Separate Problem
While high triglycerides (TG) are an independent cardiovascular risk factor, very high levels (≥ 1000 mg/dL) also increase the risk of pancreas inflammation (pancreatitis).
| Triglyceride Level | Classification | Priority Action |
|---|---|---|
| < 150 mg/dL | Normal | — |
| 150-499 mg/dL | Mild-Moderate elevation | Lifestyle; investigate underlying causes |
| 500-999 mg/dL | High | Medication may be considered; lifestyle |
| ≥ 1000 mg/dL | Very high — emergency | Urgent triglyceride lowering; pancreatitis risk; dietitian referral is mandatory |
Main Causes That Raise Triglycerides:
- Alcohol consumption
- Sugary drinks, refined carbohydrates, white flour
- Obesity and uncontrolled diabetes
- Hypothyroidism, kidney disease
- Some medications (beta-blockers, estrogen, glucocorticoids, some antipsychotics)
- Genetic disorders
G. Cholesterol in Children and Young Adults
The 2026 guideline now starts cholesterol management from childhood. Early diagnosis and treatment are life-saving in children with familial hypercholesterolemia.
When to Screen for Cholesterol in Children?
- Children aged 2 and older should have lipid measurement if there is obesity, diabetes, or a family history of premature cardiovascular disease
- Universal screening is recommended for all children aged 9-11
- Re-evaluation between ages 17-21
- Test at the earliest possible age if there is high LDL or familial hypercholesterolemia in the family
👨👩👧 If There is a Family History of High Cholesterol: If one of the parents has LDL > 190 mg/dL or a history of an early heart attack/stent/bypass, take your children to a physician and have their lipid profile measured, including Lp(a). Early treatment of familial hypercholesterolemia makes a massive difference.
H. Which Tests Should Be Done? — Checklist
| Test | What It Measures | When? | For Whom is it a Priority? |
|---|---|---|---|
| Standard Lipid Profile | Total cholesterol, LDL, HDL, TG, non-HDL | Initial evaluation + 4-12 weeks after starting medication + 1-2 times a year | Everyone; starting from age 20 |
| Lp(a) Measurement | Lipoprotein(a) concentration | At least once in a lifetime | All adults — especially families with a history of premature heart disease |
| ApoB Measurement | All atherogenic lipoprotein particles | After LDL/non-HDL targets are reached; if TG > 200, diabetes, or low LDL | Diabetes, high triglycerides, CKM syndrome |
| Coronary Calcium (CAC) Score | Calcified plaque in heart arteries | If the treatment decision is uncertain | Intermediate-risk men ≥ 40, women ≥ 45; selected borderline-risk individuals |
| hsCRP | High-sensitivity C-reactive protein (inflammation) | Additional assessment in borderline-risk individuals | Borderline risk; if ≥ 2 mg/L in two measurements, consider high-intensity statin |
⏱️ When to Retest After Starting Medication? A new lipid measurement is required 4-12 weeks after starting medication or changing the dose. Then, a check-up every 6-12 months. Once values are stable, 1 measurement per year is sufficient.
I. Frequently Asked Questions
Do I have to take cholesterol medications for life?
In the vast majority of conditions such as familial hypercholesterolemia or established heart disease, yes. However, if LDL can be sufficiently lowered through lifestyle changes, the dose may be reduced or the medication stopped in some people. This decision must be made with your physician. When medication is stopped, LDL rises again.
Are statins harmful? Do they ruin the liver and muscles?
Statins have been safely used by millions of people for decades. Serious liver damage is extremely rare. Muscle pain can occur in about 1 in 10-15 people, but it is usually mild and is resolved by adjusting the dose or changing the medication. Severe myopathy indicating muscle damage occurs in less than one in a thousand. Stopping statins poses a much greater risk than these rare side effects.
Are there always symptoms when cholesterol is high?
No. The vast majority of high cholesterol is completely asymptomatic (causes no symptoms). A person can live with high LDL for years, while the progressing atherosclerosis in their arteries grows unnoticed, manifesting suddenly with a heart attack or stroke. This is why regular screening is vitally important.
What can I do if my Lp(a) is high?
It is not yet possible to significantly lower Lp(a) with lifestyle or current medications. However, in the presence of high Lp(a), it is recommended to control other risk factors (LDL, blood pressure, smoking, diabetes) much more aggressively. New drugs specifically targeting Lp(a) (olpasiran, muvalaplin) are currently in the final stages of clinical trials.
Do natural supplements like omega-3 and garlic work?
The 2026 guideline is very clear on this: Dietary supplements do not lower LDL or triglycerides to a clinically meaningful level and do not appear to prevent cardiovascular disease. Prescription high-dose omega-3 (icosapent ethyl) is in a separate category and is different. It should not be confused with fish oil capsules sold in pharmacies.
What should I ask my physician?
- Question 1: What are my LDL, HDL, triglyceride, and non-HDL values, and what should my target be?
- Question 2: Have I ever had my Lp(a) measured in my life? Should I?
- Question 3: What is my cardiovascular risk category? (low/borderline/intermediate/high)
- Question 4: Do I need a coronary calcium score?
- Question 5: Are my current medications sufficient? Are changes needed?
- Question 6: There is a cholesterol problem in my family. Do my children need to be tested?
J. Quick Reference: Summary of the 2026 Guideline
10 MAJOR INNOVATIONS — BRIEF SUMMARY
- LDL target values have returned: Very high risk < 55, high risk < 70 mg/dL
- More accurate risk calculation with PREVENT equations: CPR model (Calculate-Personalize-Reclassify)
- Lp(a): Measurement is recommended for all adults at least once in their lifetime
- ApoB: Useful for additional risk detection, especially in diabetes and high triglycerides
- CAC score: A deciding tool in treatment uncertainties — men ≥40, women ≥45
- Early treatment is critical: High LDL starting in youth leads to more damage
- Diabetes, CKD, HIV: Medication treatment regardless of LDL level between ages 40-75
- Ezetimibe prerequisite for PCSK9 inhibitors removed: Bempedoic acid is a new option
- Dietary supplements are not recommended for cholesterol: Class 3 (harm or no benefit)
- Female-specific risk factors have become official: preeclampsia, gestational diabetes, premature menopause
📚 Source
Blumenthal RS, Morris PB, Gaudino M, et al. 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. Circulation. 2026;153. DOI: 10.1161/CIR.0000000000001423
This document has been prepared for public information purposes. Consult your physician for individual medical decisions.
A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice GuidelinesDownload
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