New Dyslipidemia Guidelines Reveal Significant Gap in LDL-C and LLT Treatment Goals

The majority of US adults are significantly above LDL-C goals, according to an analysis including the 2026 American College of Cardiology/American Heart Association dyslipidemia guidelines.1

The updated 2026 guidelines included the reintroduction of the Predicting Risk of Cardiovascular Disease EVENTs (PREVENT) equations, replacing the existing pooled cohort equations (PCEs), as well as establishing risk-based LDL-C treatment goals. These updated goals prompted a reevaluation of the proportion of patients still above new LDL-C goals to estimate the prevalence of dyslipidemia and its ensuing conditions in the US.2

The present study, conducted by Shady Abohashem, MD, MPH, the head of cardiac PET/CT imaging trials and an instructor at Harvard Medical School, and colleagues, seeks to examine the degree to which US adults are exceeding their LDL-C goals – and how many are receiving lipid-lowering therapy to reverse this.1

Abohashem and colleagues gathered data from the National Health and Nutrition Examination Survey (NHANES) 2021-2023 cycle, prioritizing adults aged 30-79 years. Response rates were 25.7% - the team adjusted survey weights for nonresponse, and no evidence was found regarding systematic nonresponse bias.1

The team estimated 10-year atherosclerotic cardiovascular disease (ASCVD) risk among patients without self-reported ASCVD or heart failure via the PREVENT base equations. The collected risk data were then categorized as low (<3%), borderline or intermediate (3-<10%), or high (≥10%). Established ASCVD was defined via self-reported coronary heart disease, myocardial infarction, angina, or stroke, while very high risk was assigned through a combination of major ASCVD events and high-risk conditions as determined by NHANES data.1

Abohashem and colleagues derived LDL-C from venous blood collected during the morning fasting subsample of the NHANES mobile examination visit. Reference goals were assigned by the patient’s risk category, with <160 mg/dL for low-risk adults, <100 mg/dL for borderline adults, <70 mg/dL for high-risk adults, <70 mg/dL for adults with ASCVD not meeting very high risk criteria, and <55 mg/dL for adults with ASCVD meeting very high risk criteria. Secondary analyses determined lipid-lowering therapy use among patients above LDL-C goals via self-reported use of prescription medication for high cholesterol.1

A total of 2313 patients were included in the analytic sample, representing roughly 177.7 million adults (87.8% in primary prevention, 12.2% in secondary). Among the primary prevention cohort, roughly 32.2% had LDL-C above guideline-recommended goals (95% CI, 29.6-34.9%). Prevalence increased among higher risk categories.1

Among low-risk adults, 9.9% were above goal. 63.6% of borderline/intermediate risk adults were above goal, and 82.7% were above goal among high-risk adults. The proportion above goal was notably higher among older, male adults. Of adults with established ASCVD, 79.6% were above goal (95% CI, 73.5-84.8%). Among adults above goal, roughly 76.1% (95% CI, 71.1-80.6%) in primary prevention and 37.6% (95% CI, 29.9-45.8%) in secondary prevention were not receiving lipid-lowering therapy.1

Abohashem and colleagues attributed the observed treatment gaps to a variety of factors, including clinical inertia, limited patient awareness, and barriers to adherence or access. Additionally, while primary prevention patients’ next step was statin initiation, secondary prevention typically included patients already on lipid-lowering therapy and required intensification with higher-intensity statins or nonstatin therapies.1

The team also reported potential limitations to the study, including reduced NHANES response rates and participant self-report of ASCVD status and use of lipid-lowering therapy. Additionally, the AHA/ACC guidelines do not explicitly state an LDL-C goal for low-risk adults.1

“These estimates reflect contemporary lipid levels prior to release of the guideline, and future studies are needed to evaluate how adoption of the updated guideline may influence lipid management and cardiovascular outcomes in practice,” Abohashem and colleagues wrote.1

References

1. Abohashem S, Martin S, Hassan I, et al. Prevalence of LDL-C Above 2026 Dyslipidemia Guideline Goals Among US Adults. JAMA. July 20, 2026. Accessed July 20, 2026. doi:10.1001/jama.2026.10529

2. 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. March 13, 2026. Accessed July 20, 2026. https://doi.org/10.1161/CIR.0000000000001423