New cholesterol guidelines emphasize earlier risk assessment and prevention

New national guidance for managing cholesterol and other blood lipids emphasizes earlier risk assessment, more personalized treatment, and long-term prevention—including, in some cases, treatment beginning as early as age 30. Experts say this approach could significantly reduce heart attacks and strokes over a lifetime.

The updated recommendations, developed by the American College of Cardiology (ACC) and the American Heart Association (AHA) in collaboration with nine other leading medical associations, reflect a growing body of evidence that long-term exposure to elevated LDL (bad) cholesterol drives the buildup of plaque in arteries and increases cardiovascular risk over time. An estimated 1 in 4 US adults have high levels of LDL cholesterol, underscoring the need for earlier detection and treatment.

Faculty in NYU Langone Health's Leon H. Charney Division of Cardiology played a key role in shaping the recommendations. Harmony R. Reynolds, MD, director of NYU Langone's Cardiovascular Clinical Research Center, served on the guideline writing committee, and Sunil Rao, MD, director of interventional cardiology, serves as chair-elect of the ACC/AHA Joint Committee on Clinical Practice Guidelines, overseeing the development of all cardiovascular clinical guidelines.

The 2026 ACC/AHA Guideline on the Management of Dyslipidemia, published March 13 simultaneously in the Journal of the American College of Cardiology and Circulation, replaces the 2018 guideline and provides a comprehensive, evidence-based framework for assessing and managing blood lipids to reduce cardiovascular risk.

A shift toward earlier intervention

A central focus of the updated guidance is identifying risk earlier in life and intervening sooner through lifestyle habits, such as maintaining a healthy weight, staying physically active, avoiding tobacco products, prioritizing sleep, and taking cholesterol-lowering medications when recommended by a healthcare professional.

Diet and exercise are critically important, and these are habits we want to establish early and maintain over a lifetime."

Dr. Harmony R. Reynolds, MD, director of NYU Langone's Cardiovascular Clinical Research Center

A new tool to assess risk earlier

The guideline recommends a new cardiovascular disease risk calculator known as Predicting Risk of Cardiovascular Disease EVENTs (PREVENT), which helps clinicians estimate the likelihood that adults ages 30 to 79 will develop atherosclerotic cardiovascular disease, a condition caused by plaque buildup in the arteries. The tool incorporates factors such as body mass index, cholesterol levels, and tobacco use to calculate both 10- and 30-year risk, helping guide earlier and more personalized treatment decisions.

"Rather than waiting until someone is at the highest risk, we now have better tools to identify risk earlier and take action sooner," said Dr. Reynolds. "We're shifting from focusing only on 10-year risk to also looking at 30-year risk, recognizing that cardiovascular disease develops over a lifetime."

Expanded testing helps tailor care to each patient

To better customize care for individual patients, the guideline introduces several new approaches. These include testing the blood for additional biomarkers, such as lipoprotein(a) and apolipoprotein B, which can help uncover hidden risk not captured by standard cholesterol measures. Coronary artery calcium scoring is also recommended for certain patients to detect early plaque buildup and guide treatment decisions when risk remains uncertain.

"Cholesterol care isn't one-size-fits-all," said Dr. Reynolds. "These additional tools give us a clearer picture of each patient so we can make more personalized decisions."

Lower LDL targets, more treatment options

The guideline emphasizes the importance of keeping LDL levels low, particularly for patients at higher risk, to reduce lifetime exposure to plaque-causing lipids. In general, people without major risk factors should aim for LDL levels below 100 milligrams per deciliter (mg/dL). For those with diabetes, a high chance of developing heart disease, or other risk factors, the goal is below 70 mg/dL. People who have already had a heart attack or stroke are advised to maintain even lower levels—below 55 mg/dL—to help prevent future events.

If lifestyle changes and statin therapy are not sufficient, the guideline highlights a growing number of treatment options, including newer oral medications and injectable therapies that can further reduce cholesterol levels.

"In general, lower LDL is better, especially over a longer period of time," said Dr. Reynolds. "Reducing exposure earlier in life can have a meaningful impact on long-term cardiovascular risk."

Cholesterol risk can begin in childhood

High cholesterol can start to impact heart disease risk even in childhood and adolescence, the guideline notes. Children may develop high cholesterol due to inherited conditions or lifestyle factors, and screening is recommended for those between ages 9 and 11 to help assess risk and guide care in partnership with clinicians, parents, and caregivers.

"Half of people with high LDL cholesterol don't have a family history of heart disease," said Dr. Reynolds. "Heart disease is common, and there can be a long period between when plaque buildup starts and when heart attack or stroke happens, so checking and understanding your numbers is critical."

A long-term approach to heart health

Ultimately, the guideline represents a broader shift in cardiovascular care—from treating disease later in life to preventing it earlier and more proactively.

"If there's one place to start, it's simple: Get up and move," Dr. Reynolds said. "Physical activity remains one of the most powerful, evidence-based ways to improve heart health, supporting both longevity and quality of life at every stage."

NYU Langone Heart is a recognized leader in preventive cardiology and lipid research, with long-standing expertise in cholesterol management and cardiovascular risk reduction. Through the Center for the Prevention of Cardiovascular Disease, researchers and clinicians have advanced understanding of how cholesterol, inflammation, and metabolic health contribute to atherosclerosis and heart disease. The work spans early detection, risk assessment, and the development of novel therapies to support more proactive, prevention-focused care.