Time Stamps

  • Highlight #1 & #2: CPR and PREVENT Score
  • Highlight #3: Updated ASCVD Risk Categories Using the PREVENT Score
  • Highlight #4: LDL Targets Are Back
  • Highlight #5: High-Risk Conditions That Bypass the PREVENT Score
  • Highlight #6: Lp(a) Screening for Everyone
  • Highlight #7: When to Use ApoB Testing
  • Highlight #8: Reproductive Risk Factors
  • Highlight #9: Using CAC to Guide Statin Therapy
  • Highlight #10: Non-Statin Therapies 

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Show Notes

Title: 2026 Lipid Guidelines: Top 10 Practice-Changing Updates

The 2026 ACC/AHA Lipid Guidelines: Top 10 Practice-Changing Highlights

  1. The CPR Framework

The guidelines1 establish a comprehensive risk stratification framework summarized by the acronym CPR:

  • C—Calculate: Utilize the new PREVENT calculator, which replaces the Pooled Cohort Equations (PCE). Unlike the PCE, which overestimates risk, PREVENT is better calibrated to reflect true risk. 
  • P—Personalize: This involves a targeted look at risk-enhancing factors: important sources of risk that the calculator misses.
  • R—Reclassify: For select cases where the treatment decision is borderline, coronary artery calcium (CAC) can be used as a “tie-breaker”.
  1. Transition to the PREVENT Score

PREVENT offers an ASCVD risk estimate over 10- and 30-year horizons in an expanded age range. It also adds a few important new variables to the PCE, including:

    • Kidney function: eGFR and albuminuria.
    • Social determinants: Geographical risk factors based on ZIP code.
  • Metabolic factors: BMI and A1C 
  1. Updated Risk Categories & Thresholds

Because the PREVENT score provides a more accurate (and typically lower) risk estimate than the PCE, the thresholds for intervention in primary prevention have been adjusted downward:

  • Low risk: <3% 10-year risk. Generally, no statin is needed for primary prevention (barring elevated 30-year risk or other critical risk factors like diabetes or CKD)
  • Borderline risk: 3% to 5%. Focus on personalization to inform the treatment decision. CAC is appropriate.
  • Intermediate risk: 5% to 10%. A statin is generally recommended, though the use of CAC is appropriate.
  • High risk: >10%. Statin recommended.
  1. The Return of LDL-C Targets

Targets are back, providing clinicians and patients with clear goals:

  • Borderline/intermediate risk (primary prevention): Target LDL-C <100 mg/dL.
  • High risk (primary prevention, rarely secondary): Target LDL-C <70 mg/dL
  • Very High Risk (most secondary prevention): Target LDL-C <55 mg/dL.
  1. “Automatic” Statin Candidates: CKD & HIV

In addition to diabetes and severe hypercholesterolemia, two additional comorbidities now place patients directly onto treatment pathways regardless of their 10-year PREVENT score:

  • Chronic Kidney Disease (CKD): G stage 3 or higher (eGFR ≤60) should be on at least the intermediate risk pathway (LDL-C <100).
  • HIV: Based on the REPRIEVE2 trial, people living with HIV are now recognized as having elevated risk and statin therapy is recommended.
  1. Universal Lipoprotein(a) Screening

Screen every adult at least once for Lp(a) elevation.

  • Why it matters: Lp(a) is genetically determined and does not correlate with standard LDL-C levels. It identifies “hidden” risk that would otherwise be missed.
  • Risk Metrics: An Lp(a) of 125 nmol/L increases lifetime ASCVD risk by 40%; a level of 250 nmol/L doubles it compared to those at the median (20 nmol/L).1
  • Clinical Pearl: Lp(a) tests often take longer to return than standard lipid panels. Inform patients ahead of time to manage expectations.
  1. Use of Apolipoprotein B (ApoB)

While LDL-C remains the primary marker of lipoprotein-mediated risk, ApoB is recognized as more appropriate for assessing cholesterol-mediated risk in specific subpopulations.

  • Target Patients: Those with high insulin resistance states: such as diabetes or prediabetes, elevated triglycerides, MASLD, and/or an “unusually low” LDL-C reflective of small, cholesterol-depleted LDL particles.
  1. Reproductive History as a “Physiologic Stress Test”

The guidelines expand the list of reproductive risk-enhancing factors, viewing pregnancy and the menstrual history as a window into future vascular and metabolic health.

  • Key Factors: PCOS, premature menopause (age <45), preeclampsia, gestational hypertension, gestational diabetes, and having a baby small for gestational age.
  • Practice Tip: Even if a patient is 65, a history of complications during a pregnancy 30 years prior remains a cardiovascular risk enhancing factor.
  1. Refined CAC Scoring Guidance

Coronary Artery Calcium (CAC) remains a “tie-breaker” for intermediate-risk patients age 40-45+.

  • CAC = 0 Agaston units (AU): Can stay off therapy (absent other compelling indication).
  • CAC 1–99 AU: Benefit from lipid-lowering therapy.
  • CAC ≥100 AU: Greater benefit from LLT, requiring more intensive goals (LDL-C <70).
  • Incidental Findings: The term “mild CAC” generally correlates to 1-99 AU in a dedicated study. “Moderate to severe CAC” should be treated on the high-risk pathway.
  1. Yes to non-statins, no to supplements

When statins and lifestyle alone do not achieve LDL-C goals, the guidelines support escalating to ezetimibe, PCSK9 inhibitors, or bempedoic acid. Conversely, they recommend against OTC dietary supplements, which lack the regulation and efficacy of prescription-grade options.3

Transcript

Dr. Ari Fish: Hi everybody. I’m Ari Fish. I’m a chief resident at Mount Sinai Hospital in New York City, and I’m really excited today to be joining Core IM to dive into the 2026 ACC/AHA lipid guidelines that just came out. I’m thrilled right now to be joined by two frontline primary care experts who can guide us a little bit more on cholesterol management based on these guidelines. So without further ado, I’d like to introduce some of our panelists. I am very excited to be joined today by Cary and Ilana.

Dr. Cary Blum: Thanks so much Ari, for that wonderful introduction to the show. I’m Cary Blum. I’m a primary care doctor at Mount Sinai. I work with Ari. I’m also a lipid enthusiast who spends a fair amount of time thinking about this stuff.

Dr. Ilana Richman: And I’m Ilana Richman. I’m a primary care doctor and general internist at the Yale School of Medicine. So happy to be here with you both. And like Cary, I’m not a cardiologist, but I am a lipid enthusiast and also have spent some time trying to wrap my mind around the guidelines. So excited to dig in today.

Dr. Ari Fish: All right, Cary, Ilana, let’s get going with the Top 10 Practice Changing Highlights from these New Lipid Guidelines. So where should we begin?

Dr. Cary Blum: All right, so let’s get started with the top two practice changing highlights. I think it’s helpful to start with the new framework suggested by the guidelines, which is summarized into a three-letter acronym, CPR. Have you heard that one before guys? CPR?

Dr. Ilana Richman: Maybe a different CPR.

Dr. Cary Blum: Yeah, not cardiopulmonary resuscitation. This is the one that’s happening all the way at the beginning of when we’re starting to think about our patient’s cardiovascular health. This one stands for calculate, personalize, reclassify, and essentially describes a general approach to identifying patient’s risk and deciding a management strategy based on that risk calculation. So for the C, that stands for calculate, we’re using a new calculator called the PREVENT score. The PREVENT score has replaced the old pooled cohort equations. It uses slightly different variables, but essentially most of the old ones like blood pressure, but now we’re also able to add additional things like GFR and proteinuria and geographical risk factors based on zip code. So the PREVENT score really is an improvement on the pooled cohort equations in terms of identifying a more precise risk. But then the framework goes even further to suggest that once we use the calculator, we are not done. We have to really think about our patient as an individual and whether or not the calculator has done them justice. This involves primarily a though process about any risk enhancing factors that may be present. And then last but not least is this reclassify step where you’re putting the personalized data together with the calculator and coming to a final decision. And if you’re not able to come to a clear decision, sometimes ordering additional testing such as coronary artery calcium can help be a tiebreaker when you’re trying to decide whether a patient may benefit from lipid lowering therapy. So those are the first two big takeaway points. This new framework is the CPR framework and our new calculator, the PREVENT score, which has replaced the pooled cohort equation.

Dr. Ilana Richman: All right, so point number three in our top 10 list is that we have somewhat different risk categories than we saw under the last set of guidelines. So in the last iteration of the guidelines, we were accustomed to calculating a person’s 10-year ASCVD risk and then recommending or considering statin therapy based on that risk. But it was known that the pooled cohort equations overestimated risk. And so in considering the threshold to start a statin, for example, the guideline authors used a slightly higher threshold than actual risk, understanding that pooled cohort equation is slightly overestimated. So in this iteration, those thresholds are lowered because the prevent equations are better calibrated and really reflect actual absolute risk. Just to be sort of explicit about what those thresholds are, a 10-year risk lower than 3% is considered low risk. And in general for primary prevention, we don’t necessarily need to start a statin absent a few other considerations. The next category is called borderline. So those are people with a 10-year risk of three to 5%. These are people where we consider risk-enhancing factors that Cary referred to. So these are the ones where we really are strongly thinking about that reclassification idea. And then the five to 10% are intermediate risk folks. Generally we would recommend a statin, although we can use CAC in this category to reclassify, and then more than 10% is high risk. So the framework is those numbers are sort of shifted down from what we might recognize from the previous iteration of the guidelines, but are really actually meant to represent similar categories of risk.

Dr. Ari Fish: Okay. So just to recap where we are so far, we’ve introduced the CPR framework, calculate, personalize and reclassify. And we also introduced that new PREVENT calculator, which replaces the pooled cohort equation and adds more individualized inputs like kidney function and even social factors like zip code. We also reviewed the updated risk categories, low borderline, intermediate, and high risk and how those thresholds are slightly lower than in prior guidelines, but really just better reflect true absolute risk. Okay, I think I’ve got it. Let’s keep it going.

Dr. Ilana Richman: All right. Our fourth highlight is that LDL targets are back. So in the last version of the guidelines, two guidelines ago, we had LDL targets, then we shifted away from them in primary prevention with a focus on starting a satin of the correct intensity and dosing. Now we’re back to LDL targets. So what are they? So the guidelines say that for people at borderline or intermediate risk, so that 10-year PREVENT score of three to 10% basically, we would recommend an LDL target of less than a hundred. Along with that, there’s also a recommendation to lower the LDL by about 30 to 49% from the baseline. For people at high risk in a primary prevention category and for some secondary prevention patients, a target of less than 70 for the LDLs is recommended. And then for those at very elevated risk, people, for example, who’ve had an event with secondary prevention and have ongoing risk factors, an LDL target of less than 55 is recommended. One thing I’ll say about these absolute targets is that as a practicing clinician, they’re easy to hang onto. They stick in your mind when you’re counseling patients or thinking about whether we need to intensify a therapy, they’re just a lot easier to remember than trying to calculate the relative reduction in the LDL from their baseline and going back through the chart. So whether this is sort of the optimal approach in terms of the data and all the rest is an important question, but I think from a pragmatic standpoint, it makes a lot of sense.

Dr. Cary Blum: I love it. I agree. I mean, I think it’s our approach for many other chronic diseases like blood pressure. We create a goal. Diabetes, we make an A1C goal. And now with hyperlipidemia, we can kind of be in the same ballpark of thought process. 

Dr. Cary Blum: So for our fifth practice changing highlight, I want to talk about those populations of folks for whom the calculator may not be as relevant because there are some patients that have elevated risk just by virtue of having certain comorbidities. And in this particular new iteration of the guidelines, patients with chronic kidney disease and HIV have now been included along with patients who have diabetes or very elevated LDL as folks for whom lipid lowering therapy should be strongly considered regardless of their 10-year PREVENT risk. Just to be a little bit more precise, patients with CKD stage three or higher, so that would be an EGFR of 60 or lower, should be on at least that intermediate risk algorithm that Ilana just mentioned. You could also use the PREVENT score to identify if they may benefit from an even more intensive strategy. And then also people living with HIV more recently showed even in low risk cohort to benefit from statin therapy in the REPRIEVE trial, that’s been incorporated now into the new guidelines. So I love this because it’s simple. We don’t have to go through the calculator. So just by virtue of having either EGFR of 60 or lower your HIV at a minimum, that would put your patient onto that intermediate risk pathway where you’re targeting an LDL goal of less than 100.

Dr. Ilana Richman: All right, practice changing highlight number six is lipoprotein(a) screening for everyone. So this I think actually really does feel like a big shift from previous guidelines. So in the past, lipoprotein(a) testing was sort of optional and recommended as something we could evaluate as a risk enhancing factor, but here we’re seeing a stronger recommendation for screening for everyone. Lipoprotein(a) has some interesting features. It’s largely genetically determined. It does not necessarily correlate with other lipids, so with LDL and can really identify this other dimension of risk that can be sort of hiding in the background unless we specifically check for it. We don’t at this time have medications that directly lower lipoprotein(a) on the market, although many are in development and in trials, and I think we’ll see treatments for lipoprotein(a) in the next couple years. But in the meantime, our approach is really thinking about how elevated lipoprotein(a) changes our approach to global cardiovascular risk reduction. So these are patients in whom we might think about intensification of therapy or even use of a PCSK9, which secondarily can lower lipoprotein(a) by maybe 10 or 20%. So I think we’ll really start to become more comfortable with ordering and interpreting lipoprotein(a), and it’s a way in which I think the guidelines have really shifted and changed from the previous version.

Dr. Cary Blum: Absolutely. I couldn’t agree more, Ilana. For me, over the past month, I’ve been checking a lot more lipoprotein(a), and it is an important risk factor. Values of 250 double one’s lifetime risk of experiencing an ASCVD event and values of about 125 increase one’s lifetime risk by 40% compared to patients with regular LP(a) levels. So it’s a very important risk factor that’s often hiding in the background and will not be uncovered unless you check for it.

Dr. Ari Fish: So Cary, I’m just thinking a little bit about from a resident perspective, when we have a new patient in clinic and we’re getting baseline labs, do you feel like in addition to getting hemoglobin A1C lipid panel and understanding a little bit more about their baseline, would these new guidelines indicate that maybe adding an LP(a) for any new patient coming into clinic would be appropriate?

Dr. Cary Blum: Generally, yes. And for me, that’s kind of crept into my practice. One thing that’s been annoying is for me, the LP(a) takes way longer to come back than the rest of the labs. So I’ve found that it’s actually really important to communicate with the patient about this particular test before you order it to let them know what you’re checking for, that it’s going to take a little bit longer to come back and how, if it’s elevated, that may impact your outlook on their risk. Because for a young patient without other risk factors, if you plug them into the PREVENT and their 10-year risk is like 0.5%, a slightly elevated LP(a) is probably not going to make me put them on a statin, but it might be helpful for them to know that that’s a risk factor that they’re likely to have for the rest of their life. And as they get older and maybe accumulate additional risk factors, it may lower the threshold to think about lipid lowering therapy and it may provide additional motivating factors for getting into a healthy cardiovascular lifestyle. So I think in general, by default, it’s a good test to order.

Dr. Cary Blum So our seventh big practice changing highlight from the new guidelines is the use of apolipoprotein B testing as an adjunct to LDL cholesterol and other measures of lipoprotein-mediated risk. So as we’ve done for many, many decades, and as we’ve done so far in this podcast, we’ve discussed LDL cholesterol as the primary biomarker that we’re using to assess cholesterol-mediated risk and assess treatment response. The sad reality is that LDL cholesterol is the one we know about best, but it’s not the one that we know works the best. Apolipoprotein B is more precise for an average patient, and there tends to be a certain subpopulation for whom the LDL cholesterol does not work as well and will under-risk your patient. That tends to be patients who have high insulin resistance levels. So they may have diabetes, they may have elevated triglycerides, or an unusually low-looking LDL cholesterol. Those are folks in whom checking in ApoB may help identify that subpopulation that would benefit from additional more intensive treatment.

Dr. Ari Fish: Thanks, Cary. And just a quick reminder for those who’d like to dive in a bit deeper to LP(a) and apolipoprotein B. There’s an excellent Core IM five pearls  episode reviewing this topic much more in depth. So be sure to take a listen if you have a minute.

Dr. Ilana Richman: All right, so our eighth practice changing highlight again gets at this idea of risk reclassification. The guidelines now identify an expanded set of reproductive risk enhancing factors. So these include things like PCOS and premature menopause, which is defined as menopause younger than age 45, and also a number of conditions that can arise during pregnancy. This includes things like gestational hypertension, but also preeclampsia, having a baby that’s small for gestational age and gestational diabetes. So in the last probably 20 years, all these things have been recognized to confer long-lasting cardiovascular disease risk, and we’re increasingly thinking about identifying these in our patients.

Dr. Ari Fish: So I think this is quite interesting and would absolutely change my management, especially if we have a new patient coming in. I don’t always naturally think to talk to them about issues that they went through during their pregnancy, especially if that was 20, 30 years prior.

Dr. Cary Blum: Ari, point well taken. If we’re seeing a 65-year-old woman, we’re not necessarily taking a really in – depth OB history. But the way I think about this is that pregnancy involves a lot of additional physiologic stress from the standpoint of vascular health and insulin sensitivity and essentially gives you a little bit of a glimpse of what might happen if your patient were to undergo a stress test almost in a way. It’s a physiologic stress test. So a lot of risk factors that may become relevant later in the patient’s life could get uncovered during this very important period of time.

Dr. Ari Fish: Just to tie this together, next time I’m in clinic, I’m really going to lean into that P of CPR that personalize by asking appropriate questions about reproductive history like premature menopause, gestational diabetes, preeclampsia. And I think it’s a good reminder for me and that risk isn’t just about what’s in these calculators, but also what we can uncover during our in – depth discussions with patients.

Dr. Ilana Richman: I 100% agree with that.

Dr. Cary Blum: So let’s move on to our ninth practice changing highlight. This is involving coronary artery calcium, also known as CAC. CAC scoring is something that we’ve known about for years, but we really are only starting to become more comfortable with in clinical practice. What is it? Well, basically you get this score whenever somebody has a non-con chest CT. Sometimes it’s a dedicated one, which is specifically looking for coronary artery calcium. And in that case, you get a score, which is called an Agatston score. But what it is essentially a calculation of the surface area of calcium that’s present in coronary arteries. And we know that if there’s more calcium, there’s more plaque. And if there’s more plaque, there’s more probability of any one of those plaques rupturing. And so quantifying the total amount of plaque can be helpful in helping to make risk more precise. The new guidelines give us more guidance than the old ones do, but it’s still essentially used in the same way. So the old guidelines suggested that in patients who have either a borderline or intermediate risk prediction from the calculator, you may decide to order a CAC score as an additional data point to help make the risk estimate more precise so that patients without any CAC potentially could stay off of lipid lowering therapy, whereas the presence of coronary artery calciums generally would be an indication for therapy. But that’s kind of where they stopped and the new guidelines are now expanding upon that to give us more guidelines in terms of exactly how much CAC should correlate with what treatment strategy. So we still understand that having no coronary artery calcium in intermediate risk patients who are 50 or older essentially predicts no additional benefit from statin therapy. Whereas once your CAC score is one or greater, you start to see the curves separate a bit and lipid lowering therapy is beneficial.

The new guidelines suggest that CAC scores of a hundred or greater should be treated more intensely. The other great thing that the guidelines do is now give us a little bit more of an idea of what to do with results that we weren’t expecting. So the classic case there is lung cancer screening. Occasionally, you’ll see a result come back with moderate to severe visual coronary artery calcium. Those patients generally should be treated on the high risk pathway, LDL less than 70. Or if it’s more of a mild CAC picture, we could probably get away with more of the intermediate risk strategy of less than a hundred.

Dr. Ilana Richman: I think there’s a lot of discussion about this idea of downgrading risk in people in that intermediate range and is that really valuable given that we know that statins are generally safe and well tolerated? But I will say that it’s not unusual for people not to want to take medications. Who wants to take a medication? I can totally relate to that idea. And so for a subset of people who really would like to avoid medication, this does help us, I think, reclassify which patients can safely hold off on a statin versus those that really ought to be on it.

Dr. Ari Fish: So Cary and Ilana, would you say that the CAC can really be used as a tiebreaker when we’re looking from a perspective of primary prevention in this intermediate risk category to help us guide our statin decision-making?

Dr. Cary Blum: Yeah, the best use case for CAC is in intermediate risk patients who are older than 45 to 50, so have had at least that amount of time to calcify if they’re going to calcify when you basically need a tiebreaker, just like you said, Ari. It’s a great way of putting it.

Dr. Ilana Richman: All right. And then rounding out our top 10 with number 10 for our practice changing highlight, the role of non-statin medications. So the guidelines call for the expanded use of non-statin medications in primary prevention when we’re trying to meet those LDL goals. And I would say even before these guidelines, I’ve seen increasing use of non-statin medications like ezetimibe to try to drive down the LDL. The guidelines also talk about using other medications for primary prevention, including PCSK9 inhibitors and Bempedoic acid. And so all these are options depending on the clinical context and the person’s risk for achieving those LDL goals. The guidelines importantly recommend against using “dietary supplements.” I think this is really meant to refer to things like over-the-counter fish oil. Over-the-counter fish oil is distinct from prescription-grade fish oil, which is highly refined. For example, icosapent-ethyl, which has some data around its efficacy for cardiovascular risk reduction. Over-the-counter fish oil not effective along with a host of other kinds of supplements that patients often turn to because of claims around cardiovascular risk reduction. So I think we can clearly counsel patients that these are not recommended, not effective. And of course, any over-the-counter supplement is not regulated in the same way as a pharmaceutical product by the FDA and has generally unknown risks, potency, purity, and all the rest. I’ll also add that I practice in a federally qualified health center where many of our patients are low income, and I’m often shocked by patients who come into clinic with a plastic bag full of supplements that are really expensive. And I really hold the industry accountable for the claims that they make and the way in which these supplements are marketed toward patients. These people end up spending a lot of money on things that they are hopeful will be helpful, but I don’t think the evidence is there, nor are the products regulated. And so I really try to steer my patients away from it, often in part because I think it’s basically a waste of their money.

Dr. Cary Blum: I think that’s a huge point, Ilana, that a lot of patients don’t really realize. If you’re buying something from a pharmacy that comes in a bottle, it seems pretty legit. And I think that discussing that with patients can be a really important moment. I often will use this as sort of a way to segue back into a discussion about lifestyle because often when there’s an aversion to medication and it’s more acceptance of supplements, that may be a patient who may be more amenable to conversations about healthy eating and ways that they could shift their diet around. So that may be a good direction to steer things in if questions about fish oil come up.

Dr. Ari Fish: All right, lipid lovers, those are your top 10 practice changing highlights from the 2026 ACC AHA lipid guidelines. So let’s do a quick recap just to close this out and go over what we learned today. So we started by learning to use the CPR framework that calculate, personalize, and reclassify. We calculate specifically using the new prevent calculator, which replaces the pooled cohort equation. Then we’ll personalize and reclassify when appropriate. We learned that LDL targets are back and they’re used in conjunction with percent LDL reduction depending on our patient risk factors to risk stratify. And remember those high risk groups we learned about today, especially advanced CKD and HIV patients. We are now going to check an LP(a) once in all adults, and we’ll also use apolipoprotein B when we’re concerned about any type of residual risk. And don’t forget about those expanded risk enhancers, especially getting a thorough reproductive history on the appropriate patients.

We learned to use our CAC score to help refine our decision-making, but really not to override any clear risk. And finally, we’re going to escalate therapy when needed, especially with non-statin medications, but we’ll skip those supplements that really just don’t have the evidence to back them up. So huge thanks to Core IM and to Cary and Ilana for joining. And be sure to join us for part two of this lipid series where we’ll walk through cases and really try to dig into exactly how to apply these guidelines in practice. Until next time. 

References