High cholesterol is one of the most significant risk factors for heart disease, the leading cause of death in the United States. Cardiovascular disease, including heart disease and stroke, kills 2,500 Americans every day — about one person every 34 seconds. The new 2026 American College of Cardiology and American Heart Association cholesterol guidelines aim to lower that risk by focusing on earlier prevention, more proactive treatment and more personalized care.
Dr. Donald Yakel, a cardiologist at Novant Health Heart and Vascular – Physicians Plaza in Hilton Head, said cholesterol screening helps doctors evaluate several important numbers, including HDL (“good” cholesterol) and LDL (“bad” cholesterol).
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“We’re concerned with the ratio between the two and the LDL number by itself,” Yakel said. “That’s what can tell us if you’re at risk for stroke, heart attack or heart disease later in life.”
Yakel explained what has changed in the new guidelines and what patients should know.
What’s changing with the 2026 guidelines for cholesterol management?
The 2026 guidelines encourage a more complete view of lifetime cholesterol risk. For patients, that includes:
- Evaluating cholesterol risk earlier in life, including a one-time blood test for lipoprotein(a), or Lp(a), an inherited risk marker.
- Considering more than one cholesterol-lowering medication earlier.
- Lowering the threshold for starting treatment for some patients.
- Taking a more personalized approach to treatment. We’re looking at risk based on health history, current health and genetic history. While cholesterol can be influenced by lifestyle factors, it has a strong genetic component.
- A revival of calcium scoring, a test that can tell you if you have calcium in your arteries – a risk factor for blockages and heart attack. The guidelines suggest using it if you and your doctor are unsure about next treatment steps.
Have the 2026 guidelines changed the target LDL cholesterol number, or changed when doctors consider statins?
The 2026 guidelines did not change target numbers as much as they changed the approach. The 2018 guidelines focused heavily on reducing cholesterol by a percentage. The new guidelines focus on specific treatment goals and are more aggressive.
Key LDL numbers include:
- 100 mg/dL: This is the number we want people to be at or below if they have no other risk factors. If they are higher than this, we may discuss diet and exercise changes.
- 160 mg/dL: In 2018, having an LDL of 160 mg/dL or higher was considered high cholesterol, but you may not have started medication. The 2026 guidelines urge earlier treatment. This number is when your doctor will consider medication.
- 190 mg/dL: This is considered severe high cholesterol and requires medication.
- 70 mg/dL: This is the target cholesterol level for high-risk patients. The 2026 guidelines encourage trying for 55 mg/dL, if possible.
The higher your heart disease risk, the lower your LDL cholesterol goal may be. For some people, lifestyle changes may be enough. For others, medication will now be recommended earlier, and more than one medication may be needed.
The most common medication used to treat cholesterol is statins. Statins lower the amount of cholesterol in the blood very effectively, and despite misinformation that claims otherwise, they are safe. There is no current evidence demonstrating otherwise, and anyone on a statin is closely monitored for side effects.
Why does earlier cholesterol testing matter for prevention – and how early are we talking?
Research shows that plaque can begin forming in arteries as early as your 20s or 30s. For many people, high cholesterol begins early and persists over time, but it can be managed.
The 2026 guidelines recommend:
- Screening children between ages 9 and 11
- Earlier screening for children with known risk factors
- Screening for young adults starting at age 19, with follow-up every five years
These recommendations are similar to previous guidelines, but there is greater emphasis on starting earlier.
By treating people at risk of high cholesterol earlier, we can help reduce your risk throughout your life. This is especially important for people with two or more of these risk factors: diabetes, high blood pressure, smoking history, family history of high cholesterol or elevated blood lipid levels.
Will more children need cholesterol medication?
No. The adoption of the 2026 guidelines does not mean every young person with high cholesterol needs medication. Lifestyle counseling and potentially medication if someone inherited high cholesterol are the main ways we address lifelong risk in children now.
How do the new cholesterol guidelines affect every age group?
Let me break down how cholesterol management and prevention looks for different age groups.
- Children and teens. Your child’s doctor may talk about cholesterol earlier, especially if high cholesterol or early heart disease runs in your family. For most kids, this means screening and healthy habits, not medication.
- Young adults. If your LDL cholesterol is high or you have a strong family history of early heart disease, your doctor may have a conversation about lifestyle changes and, in some cases, medication.
- Ages 30 to 39. Discussions may focus more on long-term cholesterol risk.
- Ages 40 to 75. This is the age range when cholesterol medication is most commonly recommended.
- Ages 75 and older. Medication may still be an option, but treatment will remain personalized based on current heart health, other medications and personal goals.
It is important to remember these are still generalizations. The common thread is that prevention and treatment is starting earlier. Treatment will remain personalized at every age.
What is the difference between primary cholesterol prevention and secondary cholesterol prevention?
Primary prevention means lowering cholesterol to reduce the chance of a first heart attack, stroke or other heart problem.
Secondary prevention means lowering cholesterol after someone already has heart disease, plaque buildup, or has had another heart-related event. The goal is to reduce the chance of the disease getting worse or another event happening.
The new cholesterol guidelines emphasize lifetime risk, not just risk over 10 years. Why is lifetime risk important to look at?
Conditions linked to LDL cholesterol, such as heart disease, develop slowly over time. Looking at lifetime risk helps doctors identify and address problems earlier.
What should patients know about their family history?
You can ask family members if they have had an elevated cholesterol level, but there are other parts of their medical history that will be helpful, too. Ask your parents, grandparents and siblings if they have had:
- Heart disease
- Heart attack
- Heart failure
- Peripheral vascular disease
- Peripheral arterial disease
That kind of information can give your doctor a heads up that you may have risk factors for high cholesterol.
What questions should patients ask their doctors at their next checkup?
You can always ask your doctor if you should be worried about your lipid levels, especially if you know you have some risk factors. Here are some questions to start a conversation:
- What is my risk of heart disease?
- What lifestyle changes should I make?
- Would weight loss medications like GLP-1s be right for me?
The new cholesterol guidelines encourage medication earlier. Are some patients hesitant to take medications for high cholesterol?
Yes, and I try to educate every patient. It is ultimately their decision. So, I remind them of their current long-term risk and how it may increase without medication. But I give them their options, including trying more time with just diet and exercise. I am not opposed to that, but I will also bring up the new guidelines so we can discuss it based on all available information.
What should people know about living with or preventing high cholesterol?
There is almost always a pathway to a long, healthy life. Whether you have just had a heart attack or we are talking about prevention, there are so many variables. Even if you have a family history of high cholesterol, you have the power to improve your diet, lose weight and exercise. There is a lot we have control over, and more effective medications are always coming out.
What is one step someone can take today?
In my experience, weight loss moves the needle the most. Even a few pounds can make a difference. If your weight is already healthy, focus on diet, exercise and quitting smoking if needed.
Bottom line: Cholesterol prevention and management are becoming more personalized, with a stronger emphasis on early action. While genetics play a role, lifestyle changes and medication can significantly reduce risk.
