13.2 Dyslipidemia & ASCVD Risk: The 2026 ACC/AHA Guideline
Key Takeaways
The 2026 ACC/AHA dyslipidemia guideline replaces the Pooled Cohort Equations with the PREVENT-ASCVD calculator for adults aged 30–79, with 10-year risk tiers of low (<3%), borderline (3% to <5%), intermediate (5% to <10%), and high (≥10%).
LDL-C goals are back: <100 mg/dL for borderline or intermediate primary-prevention risk, <70 mg/dL for high primary-prevention risk, and <55 mg/dL (non-HDL-C <85 mg/dL) for very-high-risk secondary prevention.
Lipoprotein(a) should be measured at least once; a level ≥125 nmol/L (50 mg/dL) is a risk-enhancing factor that supports more intensive LDL-C lowering.
Female-specific enhancers such as preeclampsia and other adverse pregnancy outcomes, menopause before 40, PCOS, and autoimmune disease help personalize the PREVENT estimate toward treatment.
Statins are generally stopped before conception and avoided in pregnancy and breastfeeding, although the FDA removed the absolute pregnancy contraindication in 2021 for very-high-risk patients.
Why Lipids Matter for Women
Atherosclerotic cardiovascular disease (ASCVD)—coronary heart disease, ischemic stroke, and peripheral artery disease—is the leading cause of death in U.S. women. LDL cholesterol rises and HDL function declines across the menopausal transition, so risk climbs steeply after menopause. Women are still less likely than men to be offered statins or to reach lipid goals, which is why WHNPs must apply the guideline actively rather than waiting for symptoms.
On March 13, 2026, the ACC, AHA, and nine partner societies published a new dyslipidemia guideline that replaced the 2018 cholesterol guideline. Its themes are: treat earlier in life, estimate risk with PREVENT instead of the Pooled Cohort Equations, and bring back numeric LDL-C and non-HDL-C goals.
Screening & the Standard Lipid Panel
- Who and when: A fasting or non-fasting lipid profile in adults starting at age 20 (the guideline also endorses universal childhood screening at ages 9–11), repeated about every 4–6 years when risk is low and more often when risk factors change.
- Non-fasting is acceptable for most patients. If triglycerides are ≥400 mg/dL, repeat fasting or use a calculation (Martin-Hopkins or Sampson) that stays accurate at high triglycerides, or measure LDL-C directly.
- Lipoprotein(a): Measure at least once in adulthood; it is largely genetic and stable.
- Apolipoprotein B: Optional; most useful when triglycerides exceed 200 mg/dL, in diabetes, or when LDL-C is already <70 mg/dL but residual risk is suspected.
| Parameter | Target or Threshold | Clinical Note |
|---|---|---|
| LDL-C | Goal set by risk: <100, <70, or <55 mg/dL | Primary treatment target; percentage reduction also matters |
| Non-HDL-C | About 30 mg/dL above the LDL-C goal (for example, <85 mg/dL when the LDL-C goal is <55) | Captures triglyceride-rich remnant particles |
| HDL-C | Low if <50 mg/dL in women | A risk marker; drugs that raise HDL do not reduce events |
| Triglycerides | Normal <150 mg/dL | ≥500 mg/dL raises pancreatitis risk; ≥1,000 mg/dL is a strong indication for triglyceride-lowering therapy |
| Lipoprotein(a) | Enhancer at ≥125 nmol/L (50 mg/dL) | About 1.4-fold higher risk; ≥250 nmol/L (100 mg/dL) is about 2-fold |
The "CPR" Approach with PREVENT-ASCVD
The 2026 guideline frames primary-prevention decisions for adults aged 30–79 with LDL-C 70–189 mg/dL and no ASCVD as C-P-R:
- Calculate 10-year (and 30-year) risk with the PREVENT-ASCVD equations, which add kidney function (eGFR), account for current statin and antihypertensive use, and remove race.
- Personalize that estimate with factors PREVENT does not capture, such as lipoprotein(a), family history of premature ASCVD, and female-specific enhancers.
- Reclassify and reassess, selectively using coronary artery calcium (CAC) scoring in women aged 45 or older (men 40 or older) when the decision is uncertain.
| 10-Year PREVENT-ASCVD Risk | Category | Lipid-Lowering Approach | LDL-C Goal |
|---|---|---|---|
| <3% | Low | Lifestyle; consider drug therapy if LDL-C ≥160 mg/dL or there is a strong family history of premature ASCVD | — |
| 3% to <5% | Borderline | LDL-lowering therapy can be considered, especially with risk enhancers | <100 mg/dL |
| 5% to <10% | Intermediate | LDL-lowering therapy should be considered after a clinician–patient discussion | <100 mg/dL |
| ≥10% | High | LDL-lowering therapy recommended | <70 mg/dL |
Other groups do not need a calculator: adults aged 40–75 with diabetes, CKD stage 3–4, or HIV are recommended LDL-lowering therapy regardless of LDL-C; an LDL-C ≥190 mg/dL suggests familial hypercholesterolemia and calls for high-intensity statin therapy; and in secondary prevention, most patients with clinical ASCVD qualify for an LDL-C goal of <55 mg/dL (very high risk), with a goal of at least <70 mg/dL for the rest.
Coronary Artery Calcium
A CAC score of 0 in a borderline- or intermediate-risk woman reclassifies her risk downward and supports deferring drug therapy, unless she smokes, has diabetes, or has a strong family history. Any CAC above zero, and especially a score of 100 or more (or ≥75th percentile for age and sex), favors treatment and a lower LDL-C goal.
Female-Specific & Female-Predominant Risk Enhancers
| Enhancer | Why It Matters |
|---|---|
| Adverse pregnancy outcomes | Preeclampsia, gestational hypertension, gestational diabetes, preterm birth, and small-for-gestational-age birth reveal early vascular and metabolic vulnerability; preeclampsia roughly doubles later coronary disease and stroke risk. |
| Premature menopause (<40 years) | Spontaneous POI or surgical oophorectomy before 40 brings early estrogen loss, arterial stiffening, and adverse lipid shifts. |
| PCOS | Insulin resistance and visceral adiposity produce high triglycerides, low HDL-C, and small dense LDL. |
| Autoimmune disease | Lupus and rheumatoid arthritis accelerate atherosclerosis; young women with lupus have many-fold higher myocardial infarction risk. |
| Other markers | Persistent triglycerides ≥175 mg/dL, hs-CRP ≥2 mg/L, lipoprotein(a) ≥125 nmol/L, elevated apoB, ankle-brachial index <0.9. |
Lipid-Lowering Pharmacotherapy
- Statins (first-line): High intensity lowers LDL-C ≥50% (atorvastatin 40–80 mg, rosuvastatin 20–40 mg); moderate intensity lowers it 30%–49% (atorvastatin 10–20 mg, rosuvastatin 5–10 mg, simvastatin 20–40 mg, pravastatin 40–80 mg). Myalgias are common but true statin intolerance is uncommon; check CK only for symptoms.
- Ezetimibe 10 mg: Blocks intestinal cholesterol absorption (NPC1L1); adds 15%–25% LDL-C lowering.
- Bempedoic acid: An option for statin intolerance; can raise uric acid and trigger gout.
- PCSK9-directed therapy: Monoclonal antibodies (evolocumab, alirocumab) every 2–4 weeks or the small interfering RNA inclisiran (twice yearly after loading) lower LDL-C by about 50%–60% for patients who remain above goal.
- Triglycerides: Statins remain the foundation. Icosapent ethyl reduces events in statin-treated patients with ASCVD or diabetes and triglycerides 150–499 mg/dL; fibrates and omega-3s are used mainly to prevent pancreatitis when triglycerides reach about 1,000 mg/dL.
Statins in Pregnancy & Lactation
In 2021 the FDA asked manufacturers to remove the absolute pregnancy contraindication (the former Category X) so that very-high-risk patients—such as those with homozygous familial hypercholesterolemia or established ASCVD—can make individualized decisions. For most women, practice is unchanged:
- Preconception: Use reliable contraception while on a statin, and stop it about 1–2 months before trying to conceive, or as soon as pregnancy is recognized.
- Pregnancy: LDL-C rises about 30%–50% and triglycerides often double or triple by the third trimester, so routine lipid checks are deferred. Bile acid sequestrants (such as colesevelam) are the usual option if lipid lowering is essential; severe familial hypercholesterolemia may need lipoprotein apheresis.
- Breastfeeding: Statins are not recommended during lactation; resume after weaning.
A 44-year-old woman presents for preventive cardiovascular evaluation. She had a bilateral salpingo-oophorectomy at age 38 for severe endometriosis and two pregnancies complicated by preeclampsia. She does not smoke or have diabetes, and her blood pressure is 126/78 mmHg. Her LDL-C is 140 mg/dL, and her 10-year PREVENT-ASCVD risk is 4.1%. Under the 2026 ACC/AHA dyslipidemia guideline, what is the most appropriate plan?
Withhold lipid-lowering therapy because her 10-year risk is below the 7.5% treatment threshold.
Prescribe gemfibrozil 600 mg twice daily as first-line therapy, because her triglycerides drive her risk.
Start high-intensity atorvastatin 80 mg combined with a PCSK9 inhibitor to reach an LDL-C under 55.
Discuss a moderate-intensity statin (LDL-C goal under 100 mg/dL), because her risk enhancers favor treatment.
A 56-year-old postmenopausal woman with no ASCVD or diabetes has a 10-year PREVENT-ASCVD risk of 6% and an LDL-C of 138 mg/dL. She does not smoke and has no family history of premature ASCVD. She is reluctant to begin lifelong statin therapy, so a non-contrast coronary artery calcium (CAC) scan is performed, showing an Agatston score of 0. What is the most appropriate next step?
Defer statin therapy for now, emphasize lifestyle measures, and reassess her risk periodically.
Start high-intensity rosuvastatin 20 mg because intermediate risk requires drug therapy regardless of imaging.
Prescribe ezetimibe monotherapy as an alternative to a statin.
Order invasive coronary angiography to look for non-calcified plaque.
A 29-year-old female with heterozygous familial hypercholesterolemia (baseline LDL-C 220 mg/dL) who has been well-controlled on atorvastatin 40 mg daily (current LDL-C 105 mg/dL) presents for preconception counseling. She states that she and her partner wish to conceive in the next 3 months. What is the evidence-based recommendation regarding her statin regimen?
Discontinue atorvastatin 1 to 2 months prior to attempting conception and throughout pregnancy and lactation.
Switch to rosuvastatin 10 mg daily, which has established fetal safety in all trimesters.
Continue atorvastatin 40 mg daily throughout pregnancy because her severe hypercholesterolemia overrides any fetal risk.
Discontinue atorvastatin and initiate a PCSK9 inhibitor injection throughout pregnancy and breastfeeding.
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