ONU HealthWise

Cholesterol and lipid guideline changes

Editor’s Note: The following article was written by Karen Kier, Pharmacist, on behalf of the ONU HealthWise team

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The sooner, the better is an idiom indicating speedy or early action is ideal for certain situations. The idiom can be traced back to the 15th century and is a relic of Old English.  The saying indicates an urgent request.

On March 13, 2026, the newly released 2026 American College of Cardiology (ACC) and the American Heart Association (AHA) Guideline on the Management of Dyslipidemia were published in the AHA journal Circulation. The writing of the guidelines included physicians, nurses, pharmacists, and researchers.  This was the first lipid guideline with input from so many groups including AHA, ACC, American Association of Cardiovascular and Pulmonary Rehabilitation, Association of Black Cardiologists, American College of Preventive Medicine, American Diabetes Association, American Geriatrics Society, American Pharmacists Association, American Society for Preventive Cardiology, National Lipid Association, and Preventive Cardiovascular Nurses Association.

The experts evaluated evidence published in peer-reviewed medical journals through December of 2024 to gather the best information in formulating the guideline decisions. The document is 90 pages with 18 figures and 27 tables. Extensive!

Borrowing the concept of CliffNotes (a distant relative of mine started in 1958), I will summarize some of the key concepts that have been updated since the last lipid guidelines in 2018.

The report continues to confirm the substantial relationship between lipids and heart disease known as atherosclerosis.  By controlling lipid levels, we can reduce heart disease and improve overall cardiovascular health.

The recommendation includes screening for lipid disorders earlier.  The sooner, the better! Screening should start between the ages of 9 to 11 years of age with additional screening between 19 to 21 years. After this time period, screening should continue every 5 years. In addition, healthcare professionals should start educating our youth and young adults about lipids and heart disease at the same young ages. Besides lifestyle modifications of weight and diet, medications to lower cholesterol should be considered in young adults who have a persistent LDL (bad cholesterol) above 160 mg/dL or who have a strong family history of heart disease or they score at least 10% on the 30-year risk calculator.

The guidelines are recommending a new heart disease risk calculator than previously outlined. The new equation is called PREVENT-ASCVD. The calculator is meant for adults from 30 years of age to 79 years. The calculator can be found on the AHA website at https://professional.heart.org/en/guidelines-and-statements/prevent-calculator. It produces results for a 10-year risk and a 30-year risk. 

The guidelines are recommending the CPR approach with C standing for calculate (PREVENT), P for personalize the treatment, and R for reclassify with a coronary artery calcium (CAC) score and for reassess treatment recommendations over time.

CAC is a non-invasive CT scan of the heart to see if there is any evidence of calcium buildup in the heart blood vessels.  The presence of a high CAC increases the likelihood of heart disease and more aggressive lipid lowering agents may be recommended.

LDL goals for higher risk scores (PREVENT and/or CAC) have been lowered to less than 55 mg/dL and this is a change from the previous 70 mg/dL.  For those individuals with a lower risk score, their LDL goal can still be 70 mg/dL. We will develop goals for non-HDL levels.  HDL is the good cholesterol and non-HDL is equal to total (bad) cholesterols minus HDL.  The non-HDL is simply taking the total and subtracting out the good to leave only the bad (LDL, VLDL, IDL, lipoprotein(a)). The non-HDL should be below 85 mg/dL for high risk patients and less than 100 mg/dL for borderline to intermediate risk.

New research has shed light on the dangers of lipoprotein(a) [Lp(a)] levels, which are driven by our genetic makeup and should be measured at least once in our lifetime. High Lp(a) levels drive development the blocking of the heart blood vessels leading to heart attacks and heart failure.

The guidelines added back into current therapy the concept of managing high triglycerides. It previously had been thought that triglycerides were not a major player in developing heart disease unless extremely high values existed. The treatment recommendations include lifestyle and diet changes and using a statin as first-line treatment. Other triglyceride drugs are available if necessary.

In the guidelines, the drug therapy management has not changed too much and still includes statins as first-line therapy. Other therapies can be added on or changed to with a goal of reducing LDL to goals. The new goals are more aggressive and we strive to get lower levels of LDL than in the past.

Talk to your healthcare provider about the new lipid guidelines – the sooner, the better!