Pamela B. Morris, MD, is a professor of medicine in Cardiology and the Paul V. Palmer Chair of Cardiovascular Disease Preventionat the Medical University of South Carolina. 

Ann Marie Navar, MD, PhD, is an associate professor of cardiology at the University of Texas Southwestern Medical Center.

Part 8 of a 9-part series on the 2026 dyslipidemia guidelines created in collaboration with the ACC. 

Understanding New Recommendations on FH and High Trigs in 2026 Dyslipidemia Guidelines

The 2026 ACC/AHA Dyslipidemia Guideline provides its most granular guidance yet for patients with familial hypercholesterolemia (FH) and severe hypertriglyceridemia, with new genetic testing recommendations, a novel therapy for homozygous FH, and the first extensive management framework for triglyceride-related risk across the full severity spectrum.

Writing committee members Pamela B. Morris, MD, and Ann Marie Navar, MD, PhD, walk through four distinct patient groups defined by LDL elevation and FH status. For patients with LDL cholesterol above 190 mg/dL without meeting clinical or genetic FH criteria, the LDL goal is less than 100 mg/dL, with combination therapy recommended when statins alone are insufficient. 

Heterozygous FH carries a more aggressive target of less than 70 mg/dL, reflecting the cumulative cardiovascular risk conferred by years of elevated LDL exposure. In patients with heterozygous FH and established ASCVD, the goal tightens further to less than 55 mg/dL. For homozygous FH, a rare but severe condition in which minimal to absent LDL receptor function renders most conventional therapies substantially less effective, the guideline introduces evinacumab, an ANGPTL3 inhibitor lowering LDL through a mechanism entirely independent of LDL receptor upregulation. 

Both evinacumab and lomitapide receive Class IIb recommendations in this population. Genetic testing for FH is now formally recommended, as monogenic variants can be identified in patients with LDL levels below the 190 mg/dL threshold, and genetic confirmation facilitates cascade screening among at-risk family members.

In hypertriglyceridemia, the guideline, reflecting its renamed scope as a dyslipidemia rather than blood cholesterol document, establishes ASCVD risk, not pancreatitis, is the primary concern for most patients with triglycerides below 500 mg/dL, reinforcing statin therapy as foundational in this group. Above 500–1000 mg/dL, fibrates and high-dose prescription omega-3 fatty acids are appropriate adjuncts. 

For patients with familial chylomicronemia syndrome (FCS), a rare condition marked by severe triglyceride elevation and recurrent pancreatitis resistant to standard lipid-lowering therapy, olezarsen, an APOC3 inhibitor, is now recommended. Plozasiran, approved after the guideline's evidence review concluded, represents an additional emerging option. Morris and Navar also recommend referral to a registered dietitian for patients at risk of pancreatitis, given the complexity of dietary management in severe hypertriglyceridemia.

Morris has no relevant disclosures to report. Navar reports disclosures with Amge, Arrowhead Pharmaceuticals, AstraZeneca, Bayer, Eli Lilly and Company, Esperion, Johnson & Johnson, Merck, Miga Health, NewAmsterdam Pharma, Novartis, Novo Nordisk, Sanofi, and Silence Therapeutics, among others.

Blumenthal RS, Morris PB, Gaudino M, et al. 2026 ACC/AHA/AACVPR/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Dyslipidemia: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. 

. Published online March 13, 2026. doi:10.1016/j.jacc.2025.11.016

American College of Cardiology. ACC/AHA Issue Updated Guideline for Managing Lipids, Cholesterol - American College of Cardiology. American College of Cardiology. Published March 13, 2026. Accessed March 23, 2026. https://www.acc.org/About-ACC/Press-Releases/2026/03/13/18/01/ACCAHA-Issue-Updated-Guideline-for-Managing-Lipids-Cholesterol

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Expert Insights: Recommendations on FH, Triglycerides in 2026 Dyslipidemia Guidelines

Part 7 of a 9-part series on the 2026 dyslipidemia guidelines created in collaboration with the ACC. 

Understanding Secondary Prevention Goals, Novel Lipid Therapies from 2026 Dyslipidemia Guidelines

Secondary prevention in the 2026 ACC/AHA Dyslipidemia Guideline is defined by an intensified focus on achieving LDL cholesterol goals rapidly and systematically, with a tiered framework distinguishing very high-risk patients from the broader ASCVD population and introducing updated guidance on sequencing of both established and newer lipid-lowering agents.

Ann Marie Navar, MD, PhD, a writing committee member and cardiovascular prevention specialist, outlines the characteristics defining very high-risk status: two or more prior cardiovascular events, or a single prior event accompanied by two or more high-risk features such as age over 65, active smoking, diabetes, heart failure, hypertension, or LDL above 100 mg/dL despite statin and ezetimibe therapy. For these individuals, the LDL cholesterol goal is less than 55 mg/dL. 

The guideline acknowledges this threshold represents an area of ongoing evidence generation. Data from the VESALIUS trial, which examined PCSK9 inhibition in a lower-risk ASCVD population, were unavailable during the evidence review period closing in April 2025. For patients with ASCVD not meeting very high-risk criteria, an LDL target of less than 70 mg/dL is recommended, though the guideline offers an optional recommendation of less than 55 mg/dL for clinicians preferring a uniform target across the ASCVD population.

When statins alone are insufficient to achieve goal, the guideline provides Class I recommendations for the addition of ezetimibe and/or bempedoic acid and/or a PCSK9 monoclonal antibody. Bempedoic acid, newly approved since the 2018 guideline, now carries cardiovascular outcomes support from clinical trial data in statin-intolerant patients across both primary and secondary prevention settings. Inclisiran, a small interfering RNA targeting PCSK9, receives a Class IIa recommendation for patients unable to access or tolerate PCSK9 monoclonal antibodies, with cardiovascular outcomes data still pending.

Navar and committee vice chair Pamela B. Morris, MD, note ezetimibe and statins remain the most accessible starting point given their generic availability and tolerability profile. Selection among newer agents depends on patient preference, comorbidities, bempedoic acid is contraindicated in patients with gout, and the realities of insurance coverage and drug access, which vary substantially across practice settings.

Part 6 of a 9-part series on the 2026 dyslipidemia guidelines created in collaboration with the ACC. 

Expert Insights: Why Dietary Supplements Do Not Lower Cholesterol

For the first time, the 2026 ACC/AHA Dyslipidemia Guideline includes a formal recommendation against the use of dietary supplements for lipid lowering, a position supported by randomized controlled trial evidence and one carrying significant implications for patient counseling and shared decision-making in cardiovascular prevention.

Pamela B. Morris, MD, vice chair of the writing committee, and Ann Marie Navar, MD, PhD, address this topic with candor, acknowledging the appeal of supplement-based approaches while emphasizing wishful thinking cannot override clinical evidence. 

Randomized trial data demonstrate the most commonly promoted dietary supplements, including omega-3 fatty acids in supplement formulations, vitamin D, vitamin E, vitamin C, and red yeast rice extract, fail to produce meaningful LDL cholesterol reduction or cardiovascular event reduction. The SPORT trial, comparing very low-dose rosuvastatin (5 mg) against multiple supplements including red yeast rice, found minimal to no benefit from the supplement arm in terms of LDL lowering.

Navar draws particular attention to the regulatory distinction between supplements and pharmaceuticals: the "supports heart health" labeling permitted on supplements carries no requirement for demonstrated disease prevention benefit. Red yeast rice extract, she explains, contains lovastatin as its active ingredient, but unlike a prescribed statin, it arrives without standardized dosing, pharmaceutical-grade manufacturing controls, or regulatory oversight. For patients seeking to lower LDL or reduce cardiovascular event risk, the guideline directs clinicians toward evidence-based pharmacotherapy.

This recommendation is expected to generate pushback from some patients, particularly those preferring "natural" approaches or harboring concerns about statin side effects. It reinforces the guideline's broader message: clinicians should ground these conversations in outcomes data, and the expanded pharmacologic toolkit now available, including non-statin options with robust cardiovascular outcomes evidence, leaves little clinical justification for relying on unproven supplement regimens.

Trials show most heart supplements don’t lower LDL or prevent events; learn why omega‑3s, vitamins and red yeast rice fall short of statins.

Part 5 of a 9-part series on the 2026 dyslipidemia guidelines created in collaboration with the ACC. 

Lipid Management in Special Populations from 2026 Dyslipidemia Guidelines

The 2026 ACC/AHA Dyslipidemia Guideline expands its scope of individualized guidance for several high-risk populations, including patients with diabetes, HIV, chronic kidney disease (CKD), older adults, and cancer survivors, each now addressed with more specific risk-stratified recommendations and, in some cases, formal Class I designations.

For patients with diabetes, the guideline stratifies LDL targets based on the presence of diabetes-specific risk enhancers such as albuminuria or long disease duration. An LDL goal of less than 100 mg/dL applies broadly, with intensification to less than 70 mg/dL recommended when additional cardiovascular risk factors are present. 

Writing committee member Ann Marie Navar, MD, PhD, notes ischemic cardiovascular disease has become the leading cause of death among persons living with HIV in the era of effective antiretroviral therapy. The guideline incorporates findings from the REPRIEVE trial, which demonstrated statin therapy significantly reduces cardiovascular events in this population, and now supports a formal recommendation for statin use as part of routine preventive care in persons living with HIV.

Patients with CKD and established ASCVD represent a particularly high-risk group; the guideline recommends an LDL goal of less than 55 mg/dL, driven by the elevated absolute event risk in this population and supportive subgroup data from major lipid-lowering trials. Cancer survivors with a life expectancy of two or more years are now explicitly included as a group requiring continued cardiovascular risk reduction.

For adults over age 75, Pamela B. Morris, MD, and Navar outline a nuanced approach: continuing established lipid-lowering therapy remains appropriate, while initiating statin therapy de novo should be individualized through shared decision-making, accounting for life expectancy, polypharmacy burden, and patient health priorities. 

New lipid guidelines sharpen LDL goals for diabetes, HIV, CKD, cancer survivors and seniors, highlighting statins’ power and shared decisions.

Part 4 of a 9-part series on the 2026 dyslipidemia guidelines created in collaboration with the ACC. 

Behind the Guidelines: Embracing LDL Goals in Dyslipidemia Management

One of the most practice-defining changes in the 2026 ACC/AHA Dyslipidemia Guideline is the formal reintroduction of absolute LDL cholesterol targets—a departure from the percent-reduction framework dominant since 2013 and a shift widely anticipated by clinicians seeking clearer benchmarks for therapeutic decision-making.

Pamela B. Morris, MD, vice chair of the guideline writing committee, explains the evidentiary basis for restoring absolute goals has strengthened considerably since 2018, with cardiovascular outcomes trials consistently demonstrating lower achieved LDL levels correspond to greater event reduction. Contemporary trials incorporating non-statin therapies have produced median LDL levels of 30–45 mg/dL in treated patients, with corresponding improvements in outcomes—reinforcing the principle lower is better across the risk spectrum.

The guideline preserves the evidence-based concept of percent LDL reduction as a measure of treatment intensity: high-intensity statin therapy targets a 50% or greater reduction, while moderate-intensity therapy targets 35–49%. 

These benchmarks are now paired with specific absolute LDL cholesterol goals stratified by risk. For patients at low, borderline, or intermediate primary prevention risk, the target is less than 100 mg/dL. For high-risk primary prevention individuals, the goal is less than 70 mg/dL. For those at very high risk—including patients with established ASCVD and additional risk factors—the target is less than 55 mg/dL.

Fellow committee member Ann Marie Navar, MD, PhD, offers a straightforward clinical framework: the numbers 55, 70, and 100 correspond to highest, intermediate, and lower risk, respectively. 

Navar also clarifies a nuance causing confusion in practice—these are upper thresholds, not precise targets. Patients achieving LDL levels well below the designated goal should not have therapy reduced. Across all risk categories, the evidence supports continued benefit at lower LDL concentrations, and clinicians are encouraged to pursue—not retreat from—more intensive lipid lowering whenever it is achieved.

New lipid guidance brings back LDL targets by risk, pairing percent reduction with absolute goals—and explains why lower is better.

New US guidance spotlights one-time lipoprotein(a) tests and ApoB targets to uncover hidden heart risk and fine-tune lipid therapy.

Expert Insights: Lp(a) and ApoB in the 2026 Dyslipidemia Guidelines

New guidance shows how risk enhancers and coronary calcium scores refine statin decisions, including handling incidental CAC on routine CT scans.

Understanding the 2026 Dyslipidemia Guidelines: CAC Scoring, Risk Enhancers, & Incidental CAC

New ACC/AHA lipid update explains PREVENT risk equations, updated thresholds, and when to start statins or CAC scoring to prevent heart attacks.

Understanding the 2026 Dyslipidemia Guidelines: New Risk Tools for Management

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Expert Insights: Recommendations on FH, Triglycerides in 2026 Dyslipidemia Guidelines

Understanding Secondary Prevention Goals, Novel Lipid Therapies from 2026 Dyslipidemia Guidelines

Expert Insights: Why Dietary Supplements Do Not Lower Cholesterol

Lipid Management in Special Populations from 2026 Dyslipidemia Guidelines

Behind the Guidelines: Embracing LDL Goals in Dyslipidemia Management