• Posted March 27, 2026

New Cholesterol Guidelines: What Patients and Caregivers Need to Know

The American College of Cardiology, the American Heart Association and nine other leading medical organizations have updated guidelines for managing cholesterol and lipids.

The update is the most comprehensive revision in recent years. These changes have implications for how cardiovascular risk is assessed and when treatment is begun, as well as the targets that guide clinical decision-making.

As a cardiologist who spent years caring for patients with chronic heart disease, I can tell you that cholesterol management is one of the areas in which the gap between what we know and what patients actually experience is widest. These guidelines are designed to close that gap.

What are cholesterol and lipids?

Cholesterol is a waxy, fat-like substance essential for cell structure, hormone production and the synthesis of vitamin D. While the liver produces sufficient cholesterol for the body’s physiological needs, additional cholesterol is absorbed from dietary sources.

Lipids encompass a broader category of blood fats, including cholesterol and triglycerides. Triglycerides store excess calories and provide energy between meals.

When lipid levels become imbalanced, a condition known as dyslipidemia, the risk of heart attack and stroke increases substantially. Current estimates indicate that 1 in 4 U.S. adults has elevated LDL cholesterol.

Cholesterol is typically discussed in terms of two primary types:

LDL cholesterol, often referred to as “bad” cholesterol, transports cholesterol to the arteries, where it can accumulate as plaque. Over time, this process, known as atherosclerosis, leads to arterial narrowing and increases the risk of heart attack or stroke.

HDL cholesterol, or “good” cholesterol, facilitates the removal of LDL from the arteries by transporting it back to the liver for breakdown and elimination. Higher HDL levels are generally associated with reduced cardiovascular risk, although the updated guidelines emphasize that a healthy HDL level alone does not ensure protection.

What changed in the new guidelines?

Several notable updates have emerged in the revised guidelines.

A more accurate way to estimate your risk. The guidelines introduce a new cardiovascular risk assessment tool called PREVENT. It replaces an older calculator that was found to overestimate 10-year risk by up to 40% to 50%. The updated tool incorporates routinely collected clinical data, cholesterol levels, blood pressure, age and health behaviors to estimate both 10-year and 30-year cardiovascular risk. For the first time, 10-year risk is categorized into four groups: low (less than 3%); borderline (3% to less than 5%); intermediate (5% to less than 10%); and high (10% or greater).

A set of specific targets. The guidelines establish specific LDL cholesterol targets according to risk category. For individuals at borderline or intermediate risk, the recommended target is below 100 mg/dL. For those at high risk, the target is below 70 mg/dL, and for patients with established cardiovascular disease who are at very high risk, the goal is below 55 mg/dL. Sustained reduction of LDL cholesterol over time is associated with improved clinical outcomes.

A push for early intervention. One of the most significant changes is the emphasis on earlier intervention. Lifestyle modifications such as maintaining a healthy weight, engaging in regular physical activity, avoiding tobacco and prioritizing adequate sleep remain key. However, guidelines now recommend initiating cholesterol-lowering medication sooner when lifestyle changes alone fail to achieve target levels. The rationale is clear: Prolonged exposure to elevated cholesterol allows plaque to accumulate, making reversal more difficult over time.

A new test recommendation. The guidelines now recommend that all adults to have lipoprotein(a), or Lp(a), measured at least once. Lp(a) levels are primarily determined by genetics, are minimally affected by lifestyle, and, when elevated, are associated with increased long-term cardiovascular risk. Despite its significance, many individuals have never had this simple blood test. Apolipoprotein B (apoB) testing is also recommended for patients with diabetes, elevated triglycerides or metabolic conditions, as it may provide a more accurate risk assessment than LDL cholesterol alone. When cardiovascular risk remains uncertain, a coronary artery calcium scan may help inform decisions regarding statin therapy.

A continued role for statins. Statins remain the foundation of cholesterol-lowering therapy. But for patients who do not reach their LDL target on statins alone, the guidelines outline a clearer path for adding non-statin treatments, including ezetimibe (Zetia); bempedoic acid (Nexletol), a newer oral medication; and PCSK9 inhibitors, which are injectable therapies that can produce significant LDL reductions.

A broader consideration of risk. The guidelines acknowledge that cardiovascular risk is influenced by multiple factors beyond a single measurement. “Risk enhancers” are now incorporated into risk assessment. These include such factors as family history of heart disease; chronic inflammatory conditions (including lupus or rheumatoid arthritis); cardiometabolic conditions (such as obesity or chronic kidney disease); higher-risk ancestry (including South Asian or Filipino descent); and reproductive risk markers (such as early menopause, preeclampsia and gestational diabetes). This approach enables a more comprehensive evaluation of individual risk, rather than relying solely on cholesterol levels.

A special set of recommendations for some. The guidelines provide specific recommendations for populations with chronic kidney disease; HIV; type 1 and type 2 diabetes; and individuals undergoing cancer treatment. Most lipid-lowering therapies are advised to be deferred during conception, pregnancy and lactation, the guidelines say. Cholesterol screening is recommended to begin in childhood, between ages 9 and 11, recognizing that elevated cholesterol can contribute to cardiovascular risk from an early age.

What this means for patients and caregivers

For patients, the guidelines’ central message is the importance of timely evaluation and intervention. Lp(a) testing, assessment of LDL cholesterol relative to updated targets, and attention to “borderline” cholesterol levels are now emphasized as warranting proactive discussion and follow-up.

For caregivers and family members supporting individuals with chronic heart conditions, the guidelines offer a more concrete framework for engagement. Application of the PREVENT risk calculator, the selection of appropriate biomarkers and evaluation of treatment effectiveness relative to LDL targets are now central considerations in ongoing care.

I spent many years at Massachusetts General Hospital working with patients and families navigating chronic heart disease, and one thing I learned is that the best outcomes happen when patients and caregivers feel equipped to participate in the conversation, not just follow instructions.

These guidelines give you the language and the benchmarks to do exactly that.

Evidence indicates that more than 80% of cardiovascular disease is preventable. The updated guidelines offer patients, caregivers and clinicians more precise tools to intervene earlier and with greater confidence that these efforts can yield meaningful improvements in outcomes.

About the expert

Dr. Ami Bhatt is the Chief Innovation Officer at the American College of Cardiology and Chair of the FDA Digital Health Advisory Committee — two roles that position her at the forefront of how healthcare institutions adopt, govern, and scale technology. A cardiologist trained at Harvard and Yale, and formerly at Massachusetts General Hospital, Dr. Bhatt has spent her career within the systems that deliver care, which explains why she knows where they fail. She assesses innovation based on its outcomes, asking not if a tool is technically capable but if it is effective for the clinician using it and the patient relying on it. Her work covers AI governance, digital health strategy, health equity, and the policy frameworks that decide which innovations actually get implemented.