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

Coronary artery calcium (CAC) scoring assumes an expanded and more precisely defined role in the 2026 ACC/AHA Dyslipidemia Guideline, with new structured guidance on interpretation, treatment thresholds, and the novel incorporation of incidentally identified coronary calcium from non-gated CT imaging.

In this segment of our Special Report series on the guidelines, Pamela B. Morris, MD, and Ann Marie Navar, MD, PhD, detail a comprehensive array of risk-enhancing factors able to inform treatment decisions when the clinical picture is uncertain. Beyond traditional markers of elevated high-sensitivity C-reactive protein and high LDL cholesterol, the guideline formalizes recommendations around inflammatory conditions—including rheumatoid arthritis, lupus, psoriasis, HIV, and chronic hepatitis—as well as reproductive risk markers such as early menopause, preeclampsia, gestational diabetes, and preterm delivery. These factors carry Class IIa recommendations and are intended to support shared decision-making in borderline-to-intermediate risk patients.

Regarding CAC, the guideline reaffirms a Class I recommendation for scoring in intermediate and select borderline-risk individuals when treatment decisions remain uncertain. Importantly, this does not constitute universal screening. Morris and Navar clarify CAC results are now mapped to specific LDL cholesterol targets:

• Scores of 1–99 correspond to a goal below 100 mg/dL
• Scores of 100–299 to a 50% or greater LDL reduction with a target below 70 mg/dL; scores of 300 or above to a target below 55 mg/dL
• Scores above 1000 to very high-risk management equivalent to established ASCVD

A notable advancement is guidance on incidentally detected coronary calcium from non-gated chest CT scans. While absent calcium on such imaging cannot substitute for a formal gated CAC scan, given differences in slice thickness and sensitivity, the presence of calcium provides high-specificity evidence of subclinical atherosclerosis and can now be used to guide treatment intensity. Navar notes this is particularly relevant for patients lacking access to or unable to afford dedicated CAC screening, where clinically actionable information from routine imaging should no longer be overlooked.

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.

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. J Am Coll Cardiol. Published online March 13, 2026. doi:10.1016/j.jacc.2025.11.016
2. 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