New Cholesterol Guidelines for 2026: What Changed and What It Means for Your Heart
The American College of Cardiology and the American Heart Association released new cholesterol guidelines in March 2026, the first full update since 2018. The big changes: start earlier, test for more than LDL cholesterol, and treat to clear goals.
Cholesterol is treated earlier now
Heart risk builds with every year of exposure to high cholesterol, so the guideline moves care earlier in life. Healthy habits should start in childhood. Medication can be considered in young adults with an LDL of 160 mg/dL or higher, or with a strong family history of early heart disease.
The blood test most adults have never had: Lp(a)
Lp(a), pronounced "L-P-little-a," is a type of cholesterol particle that raises the risk of heart attack and stroke on its own, separate from LDL. For the first time, the guideline recommends that every adult have it measured at least once. It also recommends screening family members of people with high levels.
Labs report Lp(a) in one of two units, so check which one your result uses. A level of 125 nmol/L or higher (50 mg/dL or higher) counts as a risk-enhancing factor, linked to about 1.4 times the heart risk. A level of 250 nmol/L or higher (100 mg/dL or higher) is linked to about twice the risk. A high result is a reason to lower LDL more aggressively and to take your other risk factors more seriously.
A newer way to estimate your risk
The guideline replaces the old risk calculator with a newer one called PREVENT. It estimates your 10-year and 30-year risk of heart disease if you are 30 to 79 and have not had a heart attack or stroke.
A calculator is only the start. The guideline calls the process Calculate, Personalize, Reclassify. After the number comes a conversation about what the calculator leaves out. For women, that includes preeclampsia, high blood pressure or diabetes during pregnancy, preterm delivery, menopause before age 40 or 45, and polycystic ovary syndrome. Each of these raises heart risk in ways a standard calculator does not capture.
A calcium scan can sharpen the picture
A coronary artery calcium scan is a quick CT scan that shows calcified plaque in the heart arteries. The guideline suggests it for men 40 and older and women 45 and older when the decision about treatment is not clear. The score can move your risk up or down and help set your treatment goal.
Treatment goals are back
The 2018 guideline focused on how much to lower LDL. The 2026 guideline brings back actual target numbers for LDL and for non-HDL cholesterol, alongside the percentage drop. Your goal depends on your risk.
For people who have already had a heart attack, stroke, or other heart disease and are at very high risk, the goal is an LDL below 55 mg/dL. Once LDL and non-HDL goals are met, a test called apoB can refine the picture further, especially in people with diabetes, high triglycerides, or a very low LDL.
Some people need treatment no matter what their LDL is
If you are 40 to 75 and have diabetes, chronic kidney disease stage 3 or 4, or HIV, the guideline recommends cholesterol-lowering treatment regardless of your LDL level. These conditions raise heart risk enough on their own.
Knowing your numbers
Cholesterol and heart-risk care is a core part of my practice. I completed dedicated training in preventive cardiology as part of my endocrinology fellowship, and I treat patients with complex lipid disorders. If you have never had your Lp(a) checked, if early heart disease runs in your family, or if your numbers have never been explained in a way that made sense, that is a good reason for a visit.
To schedule, use the Schedule Today button at the top of this site, call or text (513) 960-5360, or email info@myprecisionendo.com.
Allison Johns, MD
