Cholesterol Guidelines Are Changing: Here’s What’s New

May 22, 2026

For the first time since 2018, new guidelines for managing cholesterol were released by the American College of Cardiology and the American Heart Association. Claire Sullivan, MD, a cardiologist at University Hospitals, explains what’s new, what it means for patients and what you should know about your own cholesterol numbers.

“The new guidelines recommend using additional tools to understand when to be more aggressive in a patient’s care,” says Dr. Sullivan.

The Lipoprotein(a) Test

For years, caring for your heart has focused on low-density lipoprotein (LDL) and high-density lipoprotein (HDL) cholesterol, and that hasn’t changed. The new guidelines recommend earlier treatment and more proactive prevention, including a one-time lipoprotein(a) testing for all adults. It’s a simple blood draw, and it can be ordered by a primary care doctor.

The test measures Lp(a), a type of bad cholesterol that acts like glue, increasing plaque buildup and the risk of blood clots. High Lp(a) levels are inherited and affects 1 in 5 people. Diet and exercise won’t lower this type of cholesterol, which is why knowing your level can help to better manage your overall cardiovascular risk.

“Everyone has some level of lipoprotein(a),” explains Dr. Sullivan. “But in certain people it accumulates at higher levels and acts as an additional marker of heart risk.” If your level is normal, it will stay normal. If it’s elevated, it tells your doctor how aggressively your other cholesterol numbers need to be managed, and it signals that your close family members (parents, siblings, children) should be tested too.

Dr. Sullivan says that medications specifically targeting elevated lipoprotein(a) are likely to be available within the next two to three years, making this test increasingly important.

The Coronary Calcium Score Test

The new guidelines also recommend a coronary calcium score test for some people, which provides a picture of what’s happening inside the arteries. The test is a CT scan that takes less than five minutes and looks for calcium deposits, or plaque buildup, in the coronary arteries.

“Using these two tools together helps us to quantify risk, rather than just saying, ‘I think you’re high risk, you should take medication,’” Dr. Sullivan explains. The result can also be a powerful motivator for lifestyle change. “Sometimes the information alone is enough to help patients say, ‘These numbers are humbling to me. I’m going to start walking daily. I’m going to start watching what I eat.’”

Good candidates for a coronary calcium score include people in their 40s, 50s or 60s with risk factors such as prediabetes, a family history of early heart disease, obesity or borderline high cholesterol levels. For people with those risk factors, a coronary calcium score is recommended once every 5-10 years. It’s not recommended for people with a previous cardiac event or very high LDL, above 190 mg/dL, who are already recognized as high risk.

And while a low calcium score is reassuring, it doesn’t cancel out other serious risk factors. “If somebody has an LDL of 250 but their calcium score is zero, their lifetime risk of heart disease is still high,” says Dr. Sullivan.

Statins: Still the Backbone of Treatment

For people at high risk, statins remain the cornerstone of prevention by helping lower LDL “bad” cholesterol levels. Target levels depend on your overall risk. For most people, the general goal is an LDL under 100 mg/dL. For higher-risk individuals, including those with diabetes, the target is less than 70 mg/dL. And for patients who have already had a cardiac event, the goal is an LDL of 55 mg/dL or lower.

HDL, the “good” cholesterol, is harder to control through medication; it tends to improve as overall health and lifestyle do.

Statins offer benefits beyond LDL reduction alone. “Statins not only decrease cholesterol, but they’re also anti-inflammatory,” Dr. Sullivan explains. “They work at the level of the blood vessel lining, and help prevent plaque build-up and stabilize existing plaque. None of the other medications we have for cholesterol can promise that kind of anti-inflammatory benefit.”

This means that even when a patient needs more treatment to get their LDL low enough, that’s almost never a reason to stop their statin. Other medications work alongside statins, not in place of them, unless a patient can’t tolerate statin therapy.

For patients who can’t tolerate statins, several alternatives are recommended in the guidelines, including:

PCSK9 inhibitors: Injectable medications, such as evolocumab (Repatha) and alirocumab (Praluent), are typically administered at home every two to four weeks, tosignificantly lower LDL.
Inclisiran (Leqvio): An injection given twice a year in a doctor’s office, which works by reducing LDL production in the liver.
Ezetimibe (Zetia): A daily pill that reduces the absorption of cholesterol from the digestive tract.

“A lot of these medications aren’t new; they’ve been around for a decade or so. But this is the first time the guidelines officially recommend using them,” Dr. Sullivan notes.

What to Ask Your Doctor at Your Next Appointment

For most people, the new guidelines won’t dramatically change what happens at their next checkup. But they do offer a few questions worth asking:

If you’ve never had a lipoprotein(a) test, ask your primary care doctor if you should have one.
If you’re in your 40s or 50s with some heart disease risk factors, ask your primary care physician about a coronary calcium score test.
If you’re on a statin and your LDL still isn't low enough, ask whether adding a non-statin therapy makes sense.
If you have diabetes or have had a previous heart problem, ask your doctor if your LDL level meets the new guidelines.

Ultimately, the new guidelines reinforce something cardiologists have long emphasized: cholesterol management is not one-size-fits-all. “It’s about shared decision-making,” says Dr. Sullivan. “The goal is for patients to understand their risk and be empowered by their doctor to do everything they can to lower it.”