AHA/ACC Dyslipidemia Guidelines Reinstate LDL-C Goals, With Viet Le, DMSc, PA-C

On March 13, 2026, the American College of Cardiology (ACC) and American Heart Association (AHA) released an updated clinical guideline for the management of dyslipidemia, replacing the 2018 Guideline on the Management of Blood Cholesterol.1

Among the most major changes in these guidelines is the shift from percent reduction of LDL-C back to specific, targeted goals. The 2018 version encouraged the use of percent LDL-C reductions as a method of monitoring lipid levels and guiding lipid-lowering therapy (LLT) across the board. Additionally, secondary prevention now includes LDL-C goals as well, with recommendations shifting for LDL-C ≥190 mg/dL and familial hypercholesterolemia (FH).1,2

“I love coming back to goals,” Viet Le, DMSc, PA-C, associate professor of research and preventive cardiology PA at Intermountain Health and ACC editor in chief, told HCPLive in an exclusive interview. “It was a little nebulous to just throw out percent reduction of LDL cholesterol, so I think it’s helpful for patients and for clinicians alike to be able to see goals of where we’re going.”

Percent LDL-C reductions were widely considered vague, given their subjectivity between patients. Now, although the guidelines retain percentage reduction in LDL-C as a priority for individuals, with goals for percent reduction dependent on the level of atherosclerotic cardiovascular disease (ASCVD) risk, LDL-C and non-HDL-C treatment goals are once again forming the backbone of LLT guidance.1

Specific goals are largely determined by PREVENT risk tier. Those at borderline risk – between 3 and <5% - have a goal LDL-C of <100 mg/dL and a goal non-HDL-C of <130 mg/dL. Patients at intermediate risk, or from 5 to <10%, have a goal LDL-C of <100 mg/dL. Those at high risk - ≥10% - have a goal LDL-C of <70 mg/dL and non-HDL-C of <100 mg/dL and should be given ezetimibe if the goal is not met on a maximum statin.1

Secondary prevention markers will also incorporate LDL-C goals – patients at very high risk, or with ≥2 major ASCVD events or 1 event and ≥2 high-risk features have a goal LDL-C of <55 mg/dL and non-HDL-C <85 mg/dL and should have ezetimibe added to max statin. Patients not at very high risk, however, have an LDL-C goal of <70 mg/dL and non-HDL-C of <100 mg/dL. Additionally, based on data from CLEAR OUTCOMES, bempedoic acid and inclisiran are now formally positioned as add-on options for very high-risk patients who cannot reach goal.1

Finally, patients with severe hypercholesterolemia or FH have received recommendations as well. Patients with ASCVD have an LDL-C goal <55 mg/dL and should receive ezetimibe, while those without ASCVD but with heterozygous HF (HeFH) have a goal LDL-C <70 mg/dL with ezetimibe, PCSK9 inhibitors, and/or bempedoic acid added to max statin. Additionally, standard risk calculators like PREVENT and PCE explicitly not recommended for HeFH – the authors cite their tendency to underestimate risk. Instead, panel-based genetic testing should be used for FH.1

“This is important,” Le said. “These are individuals with 1 event and 2 or more major risk factors, or 2 or more major events. They’re very high risk. And the guidelines make this clear. Most of our patients end up in the very high risk category if they have any events. Typically, they have 2 or more risk factors with them. So, less than 55 mg/dL should really be the clarion call and the goal that we think about for most of these individuals.”

Editors’ Note: Le reports disclosures with Janssen, Pfizer, Novartis, Idorsia, Amarin, and Lexicon.

References

1. 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. Circulation. Published online March 13, 2026. doi:10.1161/cir.0000000000001423

2. Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APHA/ASPC/NLA/PCNA guideline on the management of blood cholesterol: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019;139(25). doi:10.1161/cir.0000000000000625