This is the first comprehensive update since 2018.
The American Heart Association (AHA), the American College of Cardiology (ACC), and nine other medical organizations have jointly published updated clinical guidelines for the management of dyslipidemia and blood cholesterol.
The recommendations, published in Circulation and the Journal of the American College of Cardiology, and presented at the ACC's 75th Annual Scientific Session, shift the focus toward earlier, more personalized prevention and treatment of cardiovascular disease (CVD).
Scope of the Issue
The guidelines address dyslipidemia—a medical term for any abnormality in blood lipids, including high LDL ("bad") cholesterol, low HDL ("good") cholesterol, and elevated triglycerides. High cholesterol is estimated to contribute to approximately 4.4 million deaths annually.
An estimated 1 in 4 U.S. adults have elevated LDL cholesterol, a primary contributor to atherosclerosis (plaque buildup in arteries). Medical experts state that up to 80% of cardiovascular disease is linked to modifiable risk factors.
Key Changes in the Guidelines
The updated framework recommends several significant changes to screening and treatment protocols:
-
Earlier Risk Assessment: The age for initiating cardiovascular risk assessment has been lowered from 40 to 30 years old. The guidelines recommend considering both 10-year and 30-year (lifetime) risk of heart attack and stroke. Younger individuals with specific risk factors—such as family history of early heart disease, high blood pressure, autoimmune diseases (e.g., rheumatoid arthritis, lupus), or pregnancy complications (e.g., preeclampsia, gestational diabetes, early menopause)—may be advised to undergo more frequent screenings.
-
Universal Lp(a) Testing: A one-time blood test for Lipoprotein(a) [Lp(a)] is now recommended for all adults. Lp(a) is a genetically determined form of cholesterol that is not detected by standard cholesterol panels. Levels are stable throughout life and are not altered by lifestyle changes. Elevated Lp(a) affects an estimated 64 million people in the U.S. and is associated with an increased risk of heart attack, stroke, and aortic valve disease. While no specific treatments for lowering Lp(a) are currently available, the test aids in comprehensive risk assessment.
-
Clearer LDL Cholesterol Targets: The guidelines re-establish specific target levels for LDL cholesterol:
- <100 mg/dL: For most people without cardiovascular disease (borderline/intermediate risk).
- <70 mg/dL: For high-risk individuals.
- <55 mg/dL: For very high-risk individuals, such as those with existing heart disease, fatty buildup in blood vessels, or established atherosclerotic cardiovascular disease (ASCVD).
-
New Risk Calculator (PREVENT): Healthcare providers are encouraged to use the Predicting Risk of Cardiovascular Disease EVENTS (PREVENT) calculator. This tool estimates both 10-year risk (for ages 30-79) and 30-year risk (for ages 30-59) of heart attack and stroke. It incorporates newer variables, including blood sugar and kidney function, and was developed using data from 6.6 million individuals. Updated 10-year risk categories are defined as low (<3%), borderline (3% to <5%), intermediate (5% to <10%), and high (≥10%).
-
Additional Risk Assessment Tests: Two other tests are suggested for specific patient groups to refine risk estimates:
- Coronary Artery Calcium (CAC) Scan: A noninvasive CT scan that measures calcified plaque in the arteries. Recommended for men aged 40+ and women aged 45+ with borderline or intermediate 10-year risk when treatment decisions are uncertain.
- Apolipoprotein B (ApoB): A test measuring all artery-clogging particles in the blood. Recommended for patients who have met their LDL goal but are considered high-risk, particularly those with high triglycerides, Type 2 diabetes, or cardiovascular-kidney-metabolic syndrome.
Prevention and Treatment Recommendations
Lifestyle:
The guidelines reinforce five core lifestyle pillars as the foundation of prevention:
- A heart-healthy diet (prioritizing whole foods over ultra-processed options)
- Regular physical activity (at least 150 minutes of moderate exercise per week)
- Avoidance of all tobacco products
- Quality sleep (adequate duration and consistency)
- Maintaining a healthy weight
Medication:
- Statins: Remain the primary and first-line treatment for high cholesterol. The guidelines recommend statin therapy for adults aged 30 and older with LDL cholesterol levels of 160 mg/dL or higher. For individuals with a 10-year PREVENT-ASCVD estimate of 5% to <10% (intermediate-risk), moderate-intensity statin therapy is recommended. Generic statins are noted as being widely available and relatively inexpensive.
- Additional Therapies: For patients who do not achieve targets with statins alone, or who have very high LDL, the guidelines reference other agents such as ezetimibe, bempedoic acid, and injectable PCSK9 inhibitors. The high cost of PCSK9 inhibitors (approx. $5,000/year) is noted as an economic barrier.
- Hypertriglyceridemia: For very high triglycerides (above 500 mg/dL), which can indicate a risk for pancreatitis, new treatments such as olezarsen and plozasiran are mentioned for significant reduction.
Childhood Screening
The guidelines acknowledge that high cholesterol and atherosclerosis can begin early in life. They recommend universal cholesterol screening for all children aged 9 to 11 years to identify conditions like familial hypercholesterolemia and lifestyle-related lipid abnormalities before symptoms develop. Screening is recommended at age 2 or older for those with a family history of premature ASCVD or severe hypercholesterolemia.
Related Research and Future Considerations
The guidelines were published concurrently with findings from the VESALIUS-CV clinical trial, which demonstrated significant reductions in cardiovascular events in high-risk patients without prior stroke or heart attack when using evolocumab (a PCSK9 inhibitor) to achieve median LDL levels of 45 mg/dL. An accompanying editorial suggests future updates may further emphasize lowering LDL-C to below 55 mg/dL for a broader range of high-risk patients.
Expert commentary also notes that future recommendations will need to adapt to evolving understandings of risks from vaping and cannabis and changes in the clinical definition of obesity.