Earlier this year, the American College of Cardiology/American Heart Association released the 2026 Guideline on the Management of Dyslipidemia, replacing its last iteration, the 2018 AHA/ACC Guideline on the Management of Blood Cholesterol.
The updated guidelines reflected many shifts in how medical professionals now approach cholesterol and heart disease.
Recently, Mass General Brigham researchers found that almost one out of every three adults without heart disease in the United States have LDL, or “bad”, cholesterol levels above the goals set by the 2026 guideline.
For those who have already had a heart attack, stroke, or other cardiovascular event, this figure jumps to almost four in five.
The 2026 guideline recommends specific target goals before prescribing medication, such as keeping LDL cholesterol levels at under 55 milligrams per deciliter (mg/dL) for very high risk individuals, and at under 70 mg/dL or under 100 mg/dL depending on baseline primary risk.
However, it also strongly emphasized personalized targets.
Medical News Today spoke to three experts to discuss whether people should revise their cholesterol targets, what medications are available to lower LDL levels, and whether dietary supplements can help:
Experts said the main takeaway from the 2026 ACC/AHA guideline was the reintroduction of specific LDL-C targets, universal Lp(a) screening, and the inclusion of children to assess familial risk.
For example, the guideline now recommends that cholesterol screening start in childhood at ages 9–11, which then should be repeated at ages 19–21, and every 5 years in adults to track and spot lifelong risk early.
Aman pointed out that the updated guideline introduced a new risk calculator called PREVENT, which expands the age of screening from ages 30 to 79 years, up from the previous range of ages 40 to 75 years.
It also provides 10- and 30-year risk estimates for heart disease and considers kidney function as a risk factor.
He also listed two important changes. First, that every adult should be tested for lipoprotein(a), or Lp(a), at least once. Testing of first-degree family members is recommended when Lp(a) is elevated.
Second, that calcium score testing in men aged 40 years or older and women aged 45 years or older is recommended when the decision about lipid-lowering therapy is at intermediate risk.
A calcium score above 100 should have a goal LDL cholesterol of under 70. Above 1,000, the goal LDL is under 55.
“[R]ather than treating based on a single number — the LDL [cholesterol levels] — clinicians will now use an estimated total cardiovascular risk assessment. They will also look at ‘risk-enhancing’ factors — e.g. family history, chronic kidney disease, inflammatory conditions, high levels of lipoprotein[a] — and treat based on the patient’s risk level,” Hoedebecke said.
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“Thus, two individuals with the exact same level of LDL may present vastly different risks of suffering a myocardial infarction [heart attack] or ischemic stroke due to the rest of their medical profile,” he added.
On the topic of testing and treatment, Aman said patients may benefit from discussing new, lower LDL cholesterol goals with their clinicians if they are at higher risk.
“Asking your clinician about individualized LDL targets is reasonable, especially if you have a family history of early heart attack, diabetes, multiple risk factors, or established heart disease,” he said.
“One of the reasons why so many Americans continue to be under-treated is that high cholesterol is typically asymptomatic. Patients frequently do not experience physical discomfort until after years of exposure to high levels of blood cholesterol,” Hoedebecke said.
Buttar said the reasons why Americans remain untreated or undertreated were manifold.
“A lack of awareness of cardiovascular risk, concerns about or experience with side effects from statins, limited access to primary care or preventive cardiology, and inconsistent measurement and monitoring of risk factors,” she listed.
“One reason some patients discontinue their prescribed statins is due to myalgia or other musculoskeletal pain experienced while using the medication. However, actual statin intolerance appears to be less frequent than commonly believed,” Hoedebecke added.
“There is a myth that doctors get paid to prescribe statin medications, whereas statins are completely generic,” Aman also noted.
Aman further pointed out the racial disparities when it comes to statin use:
“One of the leading reasons is that many patients are never offered a statin. In the PALM registry, [t]hose never offered were more likely to be female, Black, or Hispanic. There is significant racial disparity when it comes to statin use. Statin use is significantly lower in Black (44.3%), Hispanic (33.7%), and Asian (49.2%) adults compared with White adults (58.3%),” he said.
Buttar said: “The guideline supports measuring lipoprotein a, ideally at least once in a person’s lifetime. Elevated Lp(a) is a heritable risk enhancer for atherosclerotic cardiovascular disease and can affect risk interpretation and treatment intensity.”
Aman agreed that every patient should have Lp(a) tested at least once.
“Lp(a) of 125 [or over] confers approximately 40% increased cardiac risk; 250 [or over] approximately doubles risk; 430 nanomols per liter [or over] confers approximately fourfold risk. Elevated Lp(a) should prompt more aggressive management of all modifiable risk factors and may favor earlier or more intensive lipid-lowering therapy,” he explained.
However, Buttar also stressed that not everyone needs repeat testing.
“[This] measurement is most useful when a person’s risk is uncertain or when family history suggests inherited risk. If Lp(a) is very high, clinicians may consider more aggressive LDL lowering and family screening,” she said.
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Aman said that although statins are not without side effects, other possible explanations for the aches, such as vitamin D and drug interactions, should be ruled out first.
Buttar said the guideline gives the following alternatives to statins: a different statin or a lower dose, non-statin therapies such as ezetimibe or bempedoic acid, PCSK9 inhibitors (monoclonal antibodies) or Inclisiran (for high-risk patients).
“Many times, simply changing the type of statin used, reducing the dosage, or administering a dose every other day successfully alleviates these side effects,” Hoedebecke said.
“Oral medicines like ezetimibe and bempedoic acid can be used as statin alternatives. These are often not as efficacious as statins, hence they are preferred in lower-risk population,” Aman said.
“Injectable medicines like PCSK 9 inhibitors and Inclisiran (twice-yearly injection) can be used in successfully reducing LDL by up 40-50% in higher-risk populations,” he added.
Aman also touched on Lipfrenda (enlicitide), the once-daily 20 mg pill, which was approved by the Food and Drug Administration (FDA) on July 16, 2026 to lower LDL cholesterol.
The general sentiment among doctors is that supplements are not a reliable substitute for guideline-recommended, scientifically proven lipid-lowering therapies.
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Aman reiterated that no dietary supplement has yet demonstrated significant LDL-C-lowering effects.
“The SPORT trial randomized adults at intermediate with heart disease risk to low-dose rosuvastatin (5 mg), one of six supplements (fish oil, cinnamon, garlic, turmeric, plant sterols, or red yeast rice), or placebo. Rosuvastatin reduced LDL-C by 37.9%, while none of the supplements significantly lowered LDL-C compared with placebo,” he said.
Buttar said that, compared with prescription fish oil, over-the-counter fish oil supplements have variable contents and generally inconsistent LDL-cholesterol-lowering effects.
“Prescription fish oil, Icosapent ethyl, a purified EPA product, was shown to reduce cardiovascular events in specific high risk groups in trials, but it does not substantially lower LDL in the way statins do,” Buttar said.
On the topic of red yeast rice supplements, Buttar said, “It contains monacolin K, which is chemically similar to statin therapy, lovastatin, and can lower LDL.”
She said the main concern with such supplements was product purity and potency.
“Contamination or inconsistent dosing are concerns. Because it essentially delivers a statin-like compound without regulation, clinicians generally advise caution. It is not a reliable or recommended substitute for prescribed therapy,” she added.
