Takeaway
The 2026 dyslipidemia guideline suggests focusing on individualized risk—use family history, lifetime risk, and cholesterol patterns to guide treatment. Start high‑value therapies early and pair with clear, empathetic conversations to improve outcomes.
Lifelong learning in clinical excellence | May 18, 2026 | 3 min read
By Roger Blumenthal, MD & Seth Martin, MD, MHS, Johns Hopkins Medicine
Natalie was a 55-year-old woman who’d been living with mildly elevated triglycerides (around 200 mg/dL) and LDL cholesterol that usually sat between 130 and 150 mg/dL. Her family history felt personal—her mother and maternal aunt both needed coronary artery stents in their early 60s—so understandably she came to us wanting to do everything she could to protect her heart and stay healthy for years to come.
In having conversations with many patients with similar concerns, here are the top 10 things we discuss with them from the 2026 American College of Cardiology/American Heart Association/Multisociety Dyslipidemia Guideline:
1. Assess risk
Assess risk and work to motivate patients to improve lifestyle habits. Health behavior counseling should begin in youth, and a baseline lipid panel should be done around ages 10 and 20 to rule out familial hypercholesterolemia and other inherited lipid disorders. Subsequently, lipid panels should be done at least about every five years.
2. Use a C.P.R. Strategy for all adults ages 30 and older.
C: Calculate
Calculate a person’s estimated 10-year and 30-year risk of ASCVD (atherosclerotic cardiovascular disease – heart attack/stroke) using the PREVENT-ASCVD equation.
P: Personalize
Determine if they have risk enhancers that aren’t included in the PREVENT equation.
R: Reclassify and Reasses
Reclasiffy by selective use of a coronary artery calcium scan if the patient or clinician is unclear what their ASCVD risk really is or whether a statin was necessary. Then Reassess the need for a lipid lowering medication.
3. Use the PREVENT-ASCVD score
High risk is considered a 10-year risk >10%, intermediate risk 5-9.9%, and borderline risk 3-4.9%. Using a cholesterol lowering medication such as a statin is recommended if a person’s risk is at least 5% and can be considered in a borderline risk individual after a the clinician and patient discuss potential long-term benefits and rare risks of medical therapy.
4. LDL-C goals are back.
All adults should strive for an LDL-C of < 100 mg/dL through lifestyle optimization and, if necessary, guideline-recommended pharmacotherapy. Adults at high risk should aim for an LDL-C of < 70 mg/dL and those at very high risk should aim for an even lower LDL-C of < 55 mg/dL.
5. An apolipoprotein B may be helpful
Once a person’s LDL-C and non-HDL-C goals are reached, anapolipoprotein B may be helpful if a person has elevated triglycerides of > 150 mg/dL or diabetes. If a person’s LDL-C goal is <70 mg/dL, their apoB goal is <70 and if their LDL-C goal is <55, their apoB goal is also <55.
6. Lipoprotein(a)
Lipoprotein(a), also known as Lp(a), should be measured once in a person’s lifetime. A value of >125 nmol/L is considered elevated and a value of >250 nmol/L is associated with a doubling of estimated risk. When the Lp(a) is elevated, a more proactive prevention strategy (e.g., a lower LDL-C goal) is recommended including in patients otherwise considered borderline risk.
7. Coronary artery calcium scan
A coronary artery calcium scan is the best tiebreaker if the patient is uncertain about whether or not to go on cholesterol lowering therapy. Both the absolute amount and age/gender percentile have prognostic significance.
8. Primary prevention
In primary prevention, there’s a strong indication to start a statin if a patient has Type 2 diabetes, chronic kidney disease (Stages 3-4), or HIV.
9. Non-statin LDL-C lowering therapies
Beyond statin therapy, non-statin LDL-C lowering therapies that have been demonstrated to reduce ASCVD risk include ezetimibe, bempedoic acid, and PCSK9 monoclonal antibodies.
10. For patients with triglycerides >150 mg/dL
For patients with triglycerides > 150 mg/dL, focus on weight loss if indicated, dietary improvements, better glycemic control, and increased brisk exercise. A potent statin lowers triglycerides ~20% and sometimes fenofibrate or high dose icosapent ethyl may be added to the statin.
Getting back to this particular patient, Natlie’s results showed a 10-year PREVENT-ASCVD risk of about 3% and an Lp(a) of 420 nmol/L—a level linked with about a fourfold rise in ASCVD risk. She and her internist decided to start on a statin to lower her LDL <70 mg/dL, in addition to continuing to pursue very healthy lifestyle habits.
This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.