The 2026 cholesterol guidelines are updated recommendations from the American College of Cardiology, American Heart Association, and other medical groups for managing dyslipidemia, which means unhealthy levels of cholesterol or other blood fats. These guidelines replace the 2018 cholesterol guideline and bring back clearer cholesterol treatment goals.
The updated cholesterol guidelines focus on lowering LDL cholesterol, also called “bad” cholesterol, earlier and more effectively in people with a higher risk of heart disease or stroke. They also give stronger guidance on risk assessment, lipoprotein(a), coronary artery calcium scoring, and combination treatment when one medication is not enough.
The main goal is to lower the risk of atherosclerotic cardiovascular disease, or ASCVD. This includes health problems caused by cholesterol-rich plaque buildup in the arteries, such as heart attack, stroke, and blocked arteries in the legs.
Cholesterol levels
The 2026 cholesterol guidelines include specific LDL cholesterol and non-HDL cholesterol goals based on each person’s cardiovascular risk. LDL cholesterol is a key target because high levels can build up inside the arteries and increase the risk of heart attack and stroke.
Non-HDL cholesterol is another useful number because it includes LDL cholesterol and other cholesterol particles that can also increase cardiovascular risk. Doctors may use it along with LDL cholesterol to help guide treatment.
These goals may vary based on age, medical history, family history, and other risk factors. A doctor can use these numbers together with overall cardiovascular risk to decide whether lifestyle changes, medication, or both are needed.
What’s new in the 2026 guidelines
The 2026 cholesterol guidelines include several important updates from the 2018 recommendations. These changes make cholesterol treatment more goal-based, personalized, and focused on long-term prevention.
- Clear cholesterol targets: The 2026 update brings back specific LDL cholesterol goals, instead of focusing mainly on the percentage of LDL reduction.
- PREVENT-ASCVD risk equations: These tools estimate 10-year and 30-year risk of cardiovascular disease and help doctors place people into risk groups.
- Lipoprotein(a) testing: The guideline recommends measuring lipoprotein(a), or Lp(a), at least once in a person’s lifetime because it can raise the risk of heart disease and stroke, even when standard cholesterol numbers are not very high.
- Coronary artery calcium scoring: This scan now has a larger role in checking for calcium buildup in the heart arteries and helping clarify whether treatment should be started or intensified.
- Earlier and combined treatment: The guideline places more focus on early treatment and combination therapy when needed, supporting the idea that keeping LDL cholesterol lower over time can reduce lifetime cardiovascular risk.
Overall, the 2026 changes aim to help doctors identify risk earlier, set clearer cholesterol goals, and choose treatment that better matches each person’s cardiovascular risk.
Understanding risk categories
Risk categories help doctors decide how low cholesterol should be and how intensive treatment should be. These categories are based on cholesterol levels, age, blood pressure, smoking status, diabetes, family history, previous cardiovascular events, and other factors.
Borderline and intermediate risk
People in this group may not have had a heart attack or stroke, but they may have risk factors that increase their chance of future cardiovascular disease. The LDL cholesterol goal is generally below 100 mg/dL.
Doctors may also consider family history, Lp(a), apoB, non-HDL cholesterol, or coronary artery calcium score to decide whether lifestyle changes are enough or whether medication should be considered.
High risk
High-risk people have a greater chance of cardiovascular disease. This may include people with diabetes, a high estimated 10-year ASCVD risk, or other strong risk factors.
The LDL cholesterol goal is usually below 70 mg/dL. Treatment often includes a statin, with another medication added if the goal is not reached.
Very high risk
Very high-risk people include those who already have ASCVD, especially people with a history of heart attack, stroke, or another major cardiovascular event. The LDL cholesterol goal is below 55 mg/dL.
More intensive treatment may be needed, such as a high-intensity statin plus another cholesterol-lowering medication.
Severe high cholesterol and familial hypercholesterolemia
An LDL cholesterol level of 190 mg/dL or higher is considered very high and often needs treatment, even before a 10-year risk score is calculated. This level may be linked to familial hypercholesterolemia, an inherited condition that causes very high LDL cholesterol from a young age.
Early diagnosis and aggressive cholesterol lowering are important, especially when there is a strong family history of early heart attack or stroke.
Treatment options
Treatment in the 2026 cholesterol guidelines is based on risk level and cholesterol goals. The main goal is to lower LDL cholesterol enough to reduce the risk of heart attack, stroke, and other artery-related problems.
Early intervention
Early intervention means identifying high cholesterol and cardiovascular risk before a serious event happens. This may include cholesterol screening, lifestyle changes, and medication when risk is high enough.
The guideline supports earlier action because long-term exposure to high LDL cholesterol can damage the arteries over time. Lowering LDL cholesterol earlier may help reduce lifetime cardiovascular risk.
Statins
Statins are usually the first medication used to lower LDL cholesterol. They work by reducing cholesterol production in the liver and helping the body remove LDL cholesterol from the blood.
For many adults, statins can lower the risk of heart attack and stroke. The strength of the statin depends on the person’s risk level and cholesterol goal.
Combined therapy
Some people do not reach their LDL cholesterol goal with a statin alone. In these cases, the 2026 cholesterol guidelines support adding other cholesterol-lowering medications.
Ezetimibe may be added to a statin to help lower LDL cholesterol further. Other options may include bempedoic acid or PCSK9 inhibitors, especially for people at high or very high risk, people with familial hypercholesterolemia, or people who need a larger LDL reduction.
Combination therapy is especially important for very high-risk patients. For example, a person with a previous heart attack or stroke may need more than one medication to reach an LDL cholesterol goal below 55 mg/dL.
Treatment during urgent heart conditions
For people hospitalized with acute coronary syndrome, such as a heart attack or unstable chest pain, treatment may need to be intensified quickly. This can include using high-intensity statin therapy and adding another LDL-lowering medication when needed.
Lifestyle and prevention
Lifestyle changes are recommended for all risk groups, even when medication is also needed. Healthy habits can help improve cholesterol levels and lower overall cardiovascular risk.
A heart-healthy routine includes eating more vegetables, fruits, whole grains, beans, nuts, and fish, while limiting saturated fat, trans fat, processed foods, and added sugar. Regular physical activity, weight management, and not smoking can also help improve cholesterol, blood pressure, blood sugar, and heart health.
Lifestyle changes may be enough for some people with mild cholesterol changes and low overall risk. However, people at high or very high risk often need both lifestyle changes and medication.
When to see a doctor
A doctor should be consulted when cholesterol levels are high, especially if LDL cholesterol is 190 mg/dL or higher. This level can suggest a higher lifetime risk and may point to an inherited cholesterol condition.
Medical evaluation is also important for people with a personal history of heart attack, stroke, chest pain, blocked arteries, or diabetes. These conditions can place a person in a higher risk group and may require lower LDL cholesterol goals.
People with a strong family history of early heart disease should also be assessed. This includes having a parent, sibling, or close relative who had a heart attack, stroke, or blocked arteries at a young age.