Quick Clinician Summary — 5 Critical Changes

• LDL targets are back:
  • <55 mg/dL (very high risk)
  • <70 mg/dL (high risk)
  • <100 mg/dL (primary prevention)
• Lp(a) is now a routine measurement recommendation — at least once in a lifetime for everyone.
• PREVENT-ASCVD risk calculator has replaced the old PCE.
• Combination therapy (statin + ezetimibe) is moved to an earlier stage.
• Initiate treatment in young adults if LDL >= 160 mg/dL.
• Reduce lifetime exposure to atherogenic lipoproteins.
• Initiate screening and treatment at younger ages.
• Therefore, lifestyle interventions must begin very early.

Introduction: A Comprehensive Update Replacing the 2018 Guideline 

The ACC (American College of Cardiology) and AHA (American Heart Association) published the new ‘Guideline on the Management of Dyslipidemia’ in 2026. Replacing the 2018 cholesterol guideline, this document approaches dyslipidemia assessment, treatment, and monitoring within a holistic framework.

The scope of the guideline is not limited solely to LDL cholesterol; triglycerides, Lp(a), and other lipid disorders are also detailed. The most important message for clinical practice is this: early screening, aggressive targets, and combination therapy are now built on a stronger evidence base.

1. Core Philosophy: ‘Lower LDL Earlier, for Longer’

The foundational approach of the new guideline is built on three principles:

1. Reduce lifetime exposure to atherogenic lipoproteins
2. Initiate screening and treatment at younger ages
3. Lower LDL to more aggressive targets and maintain that target

Therefore, lifestyle interventions must now begin very early, long before cardiovascular disease appears. Atherosclerosis is not treated once established; it is only slowed down or halted. Prevention is key.

2. New Model in Risk Assessment: PREVENT-ASCVD

The guideline abandons the old Pooled Cohort Equations (PCE) risk calculator in favor of the PREVENT-ASCVD risk calculator. This change is highly significant in practice:

• PREVENT takes diabetes, chronic kidney disease (CKD), and cardiovascular biomarkers into account.
• It offers a more valuable estimation across broader patient populations.
• When used alongside the CAC (Coronary Artery Calcium) score, it can facilitate decision-making in borderline cases.

Practical Note: You can access the PREVENT-ASCVD calculator via the official ACC website. Consider using the CAC score as a supportive tool for borderline risk patients.

3. LDL Targets Brought Back — The Biggest Difference from 2018

The 2018 guideline adopted an approach emphasizing percentage reduction. The 2026 guideline has clearly redefined absolute target LDL levels. This means major practical convenience for clinicians.

Secondary Prevention (Patients with an ASCVD Diagnosis)

Primary Prevention (Patients without an ASCVD Diagnosis)

What Does This Mean in Practice? If you previously set a target of 70 mg/dL for your patients with an ASCVD diagnosis, you may need to revise this plan to 55 mg/dL. The addition of ezetimibe has now been made an earlier step.

4. Lipoprotein(a) Measurement is Now a Routine Recommendation

One of the most striking innovations of the ACC/AHA 2026 is that Lp(a) screening has become a universal recommendation.

Why is it Important?

• Lp(a) is an inherited cardiovascular risk factor that does not respond to statin therapy.
• >= 50 mg/dL (approx. 125 nmol/L) -> Independently increases ASCVD risk.
• >= 100 mg/dL -> Risk increases approximately 2-fold.
• If high Lp(a) is present, a more aggressive LDL lowering strategy is recommended.

Recommendation: Lp(a) measurement at least once in a lifetime for every individual is now a Class I recommendation level. ESC 2025 also considers an Lp(a) level >50 mg/dL as a marker that refines risk stratification.

Clinical Point: Consider ordering an Lp(a) measurement from the very first visit for patients with a family history of premature cardiovascular disease, those unable to reach their LDL target despite statins, or those with an unexplained high-risk profile.

5. Early Treatment in Young Adults

The guideline defines new thresholds for young adults for early cardiovascular intervention:

The goal can be summarized in one sentence: Intervene before atherosclerosis begins.

6. Treatment Steps: Lifestyle and Medication

6.1 Lifestyle Interventions (Always the First Step)

• Mediterranean diet (the strongest evidence-based nutritional model)
• Weight control — abdominal obesity increases the risk multiplier
• Regular physical activity (at least 150 min of moderate intensity per week)
• Smoking cessation — increases HDL, reduces inflammation

6.2 Medical Therapy Algorithm

What Does This Mean in Practice? 

Combination therapy is no longer repositioned as a ‘last resort’, but rather ‘add early if the target is not met’. Especially in very high-risk patients, if the target is not reached at the first check-up, ezetimibe should be added without delay.

7. Triglyceride Management

Statins continue to be the primary therapy in triglyceride management. However, threshold values for severe elevations have been clarified:

8. Special Patient Groups

In the patient groups below, the risk should be considered high independent of the LDL level, and lipid-lowering therapy should be considered in primary prevention:

9. Practical Algorithm for the Outpatient Clinic

Aligned with the official messages of ACC/AHA 2026 and the aggressive target approach of the ESC, this algorithm can be used in routine dyslipidemia outpatient visits:

Step 1 — Basic Panel for Every Patient

• Full lipid panel (fasting or non-fasting measurement)
• Liver functions (ALT/AST)
• Creatinine / eGFR
• HbA1c or glucose status
• TSH (when necessary — hypothyroidism can be a cause of dyslipidemia)
• Lp(a) — at least once in a lifetime ACC/AHA 2026 explicitly recommends that Lp(a) be measured at least once. ESC 2025 also accepts an Lp(a) level >50 mg/dL as a marker refining risk stratification.

Step 2 — Determine the Risk

• Calculate the 10-year risk with the PREVENT-ASCVD calculator
• Refine the risk with a CAC score in borderline cases
• Familial Hyperlipidemia? Family history? Lp(a)? -> Incorporate risk multipliers

Step 3 — Determine the Target

Step 4 — Stepwise Treatment

• Lifestyle is always foundational
• Start with a statin -> add ezetimibe early if you don’t reach the target
• If reduction is insufficient, evaluate a PCSK9 inhibitor or inclisiran

10. Overall Assessment: America Approaches Europe

The ACC/AHA 2026 lipid guideline has brought the American cardiology approach significantly closer to the ESC (European Society of Cardiology) standards. The practical differences between the two guidelines have diminished:

Frequently Asked Questions (FAQ)

How is the ACC/AHA 2026 cholesterol guideline different from 2018? 

The 2026 guideline abandoned the 2018 guideline’s emphasis on percentage reduction and defined clear LDL targets (<55 mg/dL for very high risk, <70 mg/dL for high risk). In addition, it made Lp(a) measurement routine and replaced the old PCE with the PREVENT-ASCVD risk calculator.

What should your LDL cholesterol target be? 

Depending on your risk group: <55 mg/dL if there is very high risk or an ASCVD diagnosis; <70 mg/dL if high risk; <100 mg/dL if low-intermediate risk in primary prevention. These targets are determined according to the ACC/AHA 2026 guideline.

Why should Lp(a) be measured? 

Lp(a) is an inherited cardiovascular risk factor that does not respond to statins. Levels >= 50 mg/dL increase ASCVD risk, while levels >= 100 mg/dL increase the risk approximately 2-fold. The ACC/AHA 2026 recommends measuring Lp(a) at least once in a lifetime for everyone.

When are PCSK9 inhibitors used? 

When the LDL target cannot be reached despite a combination of a high-intensity statin and ezetimibe, PCSK9 inhibitors (evolocumab, alirocumab) come into play. Early use should be considered especially in very high-risk patients and those with familial hypercholesterolemia.

How is the PREVENT-ASCVD risk calculator used? 

PREVENT-ASCVD is available for free on the official ACC website. When age, gender, systolic BP, total cholesterol, HDL, diabetes, and CKD status are entered, the 10-year cardiovascular risk is calculated. It is recommended to refine the outcome with a CAC score for borderline risk patients.

References

1. ACC/AHA 2026 Guideline on the Management of Dyslipidemia. American College of Cardiology / American Heart Association. 2026.
2. ESC/EAS 2025 Guidelines for the Management of Dyslipidaemias. European Heart Journal. 2025.
3. Jones DW, Ferdinand KC, Taler SJ et al. Circulation 2025;152:e114-e218 — 2025 Hypertension Guideline.
4. Grundy SM et al. 2018 ACC/AHA Cholesterol Guideline. Circulation. 2019;139:e1082-e1143.

This article is for informational purposes only and does not replace medical advice. Always consult a physician for a definitive diagnosis and treatment.

2025 AHA / ACC / AANP / AAPA / ABC / ACCP / ACPM / AGS / AMA / ASPC / NMA / PCNA / SGIM

TABLE OF CONTENTS

1. Guideline Overview and Novelties

2. Blood Pressure Classification

3. Diagnostic Evaluation

   • In-Office Measurement — Out-of-Office Monitoring (ABPM/HBPM)

   • White Coat / Masked Hypertension

   • Secondary Hypertension Screening

4. Drug Initiation Threshold & CVD Risk Assessment

5. Lifestyle Modifications

6. Pharmacological Treatment

   • First-Line Agents and Combination Therapy

   • BP Goals

   • Medication Adherence Strategies

7. Special Populations

   • Diabetes | CKD | Heart Failure | Stroke | Pregnancy | Elderly

8. Resistant Hypertension

9. Hypertensive Emergency and Severe Hypertension

10. Team-Based Care and Follow-Up

1. Guideline Overview and Novelties

The 2025 AHA/ACC Hypertension Guideline is an updated clinical practice document that replaces the 2017 guideline, based on a comprehensive literature review from December 2023 to June 2024. The guideline is designed for all clinicians managing hypertension in primary care and specialty settings.

Top Take-Home Messages of the 2025 Guideline

• High blood pressure is the most common and modifiable risk factor for cardiovascular diseases. The general BP goal for all adults is <130/80 mmHg.
• Clinicians should collaborate with community leaders and health systems to screen all adults in their communities.
• Multidisciplinary team-based care is effective in evaluating access to medications and overcoming individual barriers.
• BP classification: Normal <120/80, Elevated 120-129/<80, Stage 1 HTN 130-139/80-89, Stage 2 HTN ≥140/≥90 mmHg.
• Lifestyle modifications (DASH diet, sodium restriction, weight loss, exercise, alcohol reduction) are strongly recommended for all adults.
• Pharmacological treatment is recommended for all adults with an average BP of ≥140/90 mmHg, and selected adults with a BP of ≥130/80 mmHg along with CVD, diabetes, CKD, or a PREVENT score of ≥7.5%.
• Single-pill combination therapy (SPC) should be preferred in Stage 2 HTN.
• Home BP monitoring + integration with a multidisciplinary team is an important tool that improves BP control.
• Severe hypertension (>180/120, no target organ damage) should be managed by initiating oral medication in an outpatient setting.
• When SBP ≥160 / DBP ≥110 mmHg is confirmed in pregnant women, medication should be initiated within 30-60 minutes.

From 2017 to 2025: Key Changes

ACEi: Angiotensin-converting enzyme inhibitor, ARB: Angiotensin receptor blocker, BP: Blood pressure, CKD: Chronic kidney disease, COR: Class of Recommendation, CVD: Cardiovascular disease, DBP: Diastolic blood pressure, eGFR: Estimated glomerular filtration rate, ICH: Intracerebral hemorrhage, MRA: Mineralocorticoid receptor antagonist, PREVENT: Predicting Risk of CVD EVENTs, RAASi: Renin-angiotensin-aldosterone system inhibitor, RDN: Renal denervation, SBP: Systolic blood pressure

2. Blood Pressure Classification

The guideline maintains the 2017 classification. BP classification should be based on an average of at least 2 readings obtained on two or more occasions.

In-Office BP Measurement — Correct Technique

• No caffeine, exercise, or smoking 30 min before measurement.
• 5 min quiet sitting; back supported, feet flat on the floor.
• Arm at heart level, no talking.
• At least 2 measurements, 1 min apart; take the average.
• Measure from both arms at the first visit.
• Correct cuff size: should encircle 80% of the arm.
• Avoid wearable devices (smartwatches, etc.) — insufficient accuracy.

Out-of-Office BP Monitoring

• ABPM (24-hour ambulatory BP): Significant if daytime ≥130/80, nighttime ≥110/65, 24-hour ≥125/75 mmHg.
• HBPM (Home BP monitoring): Measure in the morning before medication and in the evening before dinner; significant if ≥135/85 mmHg.
• Suspected White Coat HTN: In-Office ≥130/80 + ABPM/HBPM <130/80 → confirmatory test.
• Suspected Masked HTN: In-Office <130/80 + ABPM/HBPM ≥130/80 → high CVD risk.
• If SBP/DBP ≥160/100, treatment should be intensified without waiting for out-of-office monitoring.

3. Diagnostic Evaluation

3.1. Patient Evaluation — Laboratory and Diagnostic Tests

• Basic Laboratory Tests:
  • Fasting blood glucose or HbA1c
  • Lipid panel (LDL, HDL, TG)
  • Electrolytes (Na, K, Cl, bicarbonate)
  • Serum creatinine + eGFR calculation
  • Spot urine albumin/creatinine ratio
  • Urinalysis (dipstick + microscopy)
  • TSH (in suspected secondary HTN)
• ECG and Imaging:
  • ECG: Evaluation for left ventricular hypertrophy
  • Echocardiography: If clinically indicated
  • Fundoscopy: Suspected retinal damage
  • Renal Doppler: Suspected renovascular HTN
  • 24-hour urine aldosterone/cortisol: Secondary HTN
  • Sleep study: Suspected obstructive sleep apnea

3.2. Secondary Hypertension Screening 

Secondary hypertension can be seen in 5-25% of adult hypertensive patients. Further investigation should be done if any of the following clinical clues are present:

Primary Aldosteronism Screening — Important Point: The presence of hypokalemia is no longer a prerequisite for the screening decision. Screening is recommended in all patients with resistant hypertension. You do not need to discontinue antihypertensive drugs other than MRAs (spironolactone/eplerenone) before screening. During screening, MRAs must be discontinued at least 4 weeks in advance.

4. Drug Initiation Threshold & CVD Risk Assessment

The 2025 guideline uses the PREVENT™ (Predicting Risk of CVD EVENTs) model instead of the ASCVD score. The critical threshold is ≥7.5% ten-year CVD risk.

• Goal: <130/80 mmHg for all adults. Achieving <120 mmHg SBP is encouraged in cases with high CVD risk.
• About the PREVENT Score:
  • Replaced the older ASCVD (Pooled Cohort Equations) model.
  • Includes age, sex, BP, smoking, lipids, diabetes, CKD, obesity, and social determinants.
  • Online calculator: American Heart Association PREVENT calculator.
  • Threshold: ≥7.5% = high risk → initiate drug at 130/80 mmHg.

5. Lifestyle Modifications

Lifestyle modifications are strongly recommended for all adults (COR 1). Their effects on lowering blood pressure are summarized in the table below:

Practical Tips for Sodium Restriction:

• Label reading: ≤ 140 mg/serving = low sodium
• Watch out for the ‘Salty 6’: bread/rolls, pizza, sandwiches, cold cuts/deli meats, soup, burritos
• Hidden sodium: cheese, canned vegetables, ketchup, restaurant meals
• NSAID use increases sodium retention → avoid if possible
• Alcohol, caffeine, decongestants (phenylephrine, pseudoephedrine) raise BP → use with caution

6. Pharmacological Treatment

6.1. First-Line Agents

6.2. Alternative and Second-Line Agents

6.3. Drug Selection Strategy — Algorithm

• Stage 1 HTN — Monotherapy or SPC:
  • Can start with a single agent; especially in cases close to target BP.
  • Preferred: Thiazide-type diuretic, ACEi, ARB, or DHP-CCB.
  • If response is insufficient, increase dose or add a second agent.
  • Titrate slowly in elderly patients with orthostatic risk.
  • High-risk Stage 1 (ASCVD >7.5%, Black race) → Initiate combination with SPC.
• Stage 2 HTN — SPC Preferred:
  • Agents from two different classes; single-pill combination (SPC) preferred.
  • SPC: better adherence, faster BP control.
  • Recommended combination: RAASi + thiazide-type diuretic or DHP-CCB.
  • If response is insufficient, add a third agent.
• Combinations to Avoid:
  • ACEi + ARB: Risk of hyperkalemia + AKI (CONTRAINDICATED).
  • ACEi or ARB + Aliskiren: Same mechanism, high risk.
  • Verapamil/Diltiazem + Beta blocker: Bradycardia, AV block.
  • Two different BBs together: Restrict to isolated monotherapy.
• Useful Combinations:
  • RAASi + Thiazide: RAASi reduces the hypokalemic effect of the diuretic.
  • DHP-CCB + RAASi: CCB’s ankle edema is reduced by RAASi.
  • Thiazide + K+-sparing diuretic: Controls thiazide-induced hypokalemia.
  • Thiazide + Loop diuretic: Acceptable in selected conditions.

6.4. BP Goals

6.5. Medication Adherence Strategies

• Prefer 1 dose daily (adherence is higher compared to multiple doses).
• Prescribe SPC (single-pill combination) — reduces pill burden, increases adherence.
• Synchronize prescription refill tracking with medication appointments.
• Use telehealth, SMS reminders, smartphone apps.
• Screen for stress, anxiety, depression → non-adherence is higher in these groups.
• Provide simple, visual materials if health literacy is low.
• If non-adherence is detected, converse without judgment; understand the patient’s perspective.

7. Special Populations

7.1. Diabetes + Hypertension

• BP goal: < 130/80 mmHg (COR 1).
• If CKD eGFR <60 or albuminuria ≥30 mg/g is present: ACEi or ARB is recommended (COR 1) → delays progression of diabetic kidney disease.
• If mild albuminuria (<30 mg/g) is present: ACEi/ARB could be considered (COR 2a).
• Do not combine ACEi + ARB.
• Thiazide-type diuretic or DHP-CCB if RAASi is contraindicated.

7.2. Chronic Kidney Disease (CKD)

• BP Goal and Drug Selection:
  • SBP < 130 mmHg target (COR 1, Level A).
  • eGFR <60 + albuminuria ≥30 mg/g: RAASi (ACEi or ARB — not both) is recommended.
  • Check electrolytes and eGFR 2-4 weeks after initiating ACEi/ARB.
  • eGFR drop > 30% → reduce or discontinue drug; perform further investigation.
  • ACEi/ARB can be continued even at eGFR <30 (NEPHRON-D trial).
  • Prefer loop diuretic over thiazide at eGFR <30.
• Monitoring Parameters:
  • Potassium: Hyperkalemia monitoring (especially in RAASi + K+-sparing combinations).
  • Serum creatinine and eGFR: Every 2-4 weeks (upon dose change).
  • Aldosterone/renin ratio: In suspected primary aldosteronism.
  • Spot urine albumin/creatinine: Annual follow-up.
  • Minimize systolic blood pressure variability.

7.3. Heart Failure (HFrEF) + Hypertension

7.4. Cerebrovascular Disease + Hypertension

7.5. Pregnancy and Hypertension

• BP Management in Pregnancy — 2025 New Recommendations:
  • SBP ≥160 or DBP ≥110 mmHg → confirm within 15 min → initiate drug within 30-60 min (COR 1) — lower to <160/<110.
  • Chronic HTN (pre-pregnancy or diagnosed <20th week) → treat with a goal of <140/90 mmHg (COR 1 — NEW).
  • Recommend low-dose aspirin to those at risk of preeclampsia (COR 1 — NEW).
• CONTRAINDICATED Drugs in Pregnancy (COR 3 Harm — 2025 updated):
  • ACEi, ARB, direct renin inhibitors
  • Atenolol (NEW — added 2025)
  • Nitroprusside (NEW)
  • Mineralocorticoid receptor antagonists (MRA) (NEW)
• SAFE Drugs in Pregnancy:
  • Labetalol (IV and oral), hydralazine (IV), nicardipine (IV)
  • Oral: methyldopa, nifedipine LA

7.6. Elderly Patients and Resistant Hypertension

• Elderly Patient (≥65 Years):
  • BP goal: < 130/80 mmHg; frail patient → shared decision-making.
  • Orthostatic hypotension screening: Measurement at 1st and 3rd minute after standing.
  • Intensive BP lowering is still beneficial in orthostatic HTN, can be maintained with careful monitoring.
  • Combined BP variability + hypotensive episodes are associated with cognitive decline.
  • When initiating medication, use low dose, slow titration; reduce the iatrogenic fall risk.
  • Diuretics should be used more cautiously regarding fluid loss.
• Resistant Hypertension:
  • Definition: Target BP cannot be reached with the maximum tolerated 3 drugs (including a diuretic).
  • Before true resistance is confirmed: rule out non-adherence, white coat effect, drug/substance-induced HTN.
  • Review the entire medication list; remove or adjust drugs that affect BP (COR 1).
  • Investigate secondary causes (especially primary aldosteronism, OSA).
  • Add spironolactone as the 4th agent → the most effective add-on agent.
  • Renal denervation (RDN): In selected cases in resistant HTN; multidisciplinary team evaluation (COR 1).
  • Shared decision-making; discuss pros/cons of RDN vs. medical therapy.

8. Hypertensive Emergency and Severe Hypertension

Important Warning — 2025 New Recommendation: For asymptomatic severe hypertension (>180/120 mmHg) in adult patients admitted for non-cardiac reasons with no target organ damage, acute BP lowering using an additional intravenous or oral antihypertensive agent is not recommended (COR 3 Harm). This approach can cause harm and provides no benefit.

9. Team-Based Care and Follow-Up

9.1. Multidisciplinary Team-Based Care (COR 1, Level A)

9.2. Follow-Up After Treatment Initiation / Intensification

• Monthly follow-up for uncontrolled HTN patients with newly initiated medication or changed doses until target BP is reached (COR 1, B-R).
• Medication adherence + BP response should be evaluated at every visit.
• Electrolyte + creatinine check 2-4 weeks after RAASi initiation.
• Review home BP monitoring (HBPM) data prior to the clinical visit.
• EHR and patient registries: Use the registry system to identify uncontrolled HTN patients.
• Telehealth (synchronous or asynchronous): An effective tool for remote monitoring + medication titration (COR 2a, B-R).

9.3. Social Determinants of Health (SDOH) and Health Equity 

Socioeconomic status, access to food, housing conditions, exposure to stress and discrimination affect BP control. In Black adults, hypertension begins earlier, is more severe, and complications are seen more frequently. Thiazide-type diuretics and CCB monotherapy may be more effective than ACEi/ARB in this group.

• Screen for SDOH barriers in every patient (transportation, medication access, health literacy, financing).
• Consider initial combination therapy (thiazide + CCB) first in Black patients.
• Community-based health workers and team care are effective in reducing racial disparities in BP control.
• Clinical decision support systems (EHR) and patient registries should be used to proactively identify high-risk patients.

10. Quick Reference Card — Summaries for the Clinician

When Do I Initiate Medication? 

✔ BP ≥ 140/90: For everyone ✔ BP ≥ 130/80 + CVD/DM/CKD/PREVENT≥7.5% ⚠ BP 130-139 + low risk: Lifestyle first for 3-6 months

What Are My BP Goals?

• General goal: < 130/80 mmHg
• High risk: < 130 mmHg; ideal < 120 mmHg
• Pregnancy (chronic HTN): < 140/90 mmHg
• Post-Stroke/TIA: < 130/80 mmHg

What Are My First-Choice Drugs?

• Thiazide-type diuretic (chlorthalidone preferred)
• ACEi or ARB (not together!)
• DHP-CCB (amlodipine)
• Stage 2 → Prefer SPC (single-pill combination)

When Do I Investigate Secondary HTN?

• Resistant HTN (no control with 3 drugs)
• Young age (<30 y), sudden onset
• Hypokalemia (drug-induced or spontaneous)
• Adrenal incidentaloma
• Sleep apnea, family history
• Paroxysmal HTN + sweating + palpitations

Caution in Pregnancy!

• CONTRAINDICATED: ACEi, ARB, Atenolol, MRA, Nitroprusside
• SAFE: Labetalol, hydralazine, methyldopa, nifedipine LA
• SBP ≥160 / DBP ≥110 → medication within 30-60 min!

Severe HTN in Hospital — 2025 Change

• NO target organ damage → DO NOT give additional IV/oral agents (COR 3 Harm)
• Continue regular medications; treat the underlying cause

This document is a summary guide prepared for healthcare professionals based on the 2025 AHA/ACC Hypertension Guideline (Circulation 2025;152:e114–e218). Clinical decisions should be based on the original guideline text and individual patient assessment.