What changed in the 2026 cholesterol guideline?
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The biggest change is that LDL goals are back. On March 13, 2026, the new US guideline set them by risk: under 100 mg/dL, 70 or 55, with non-HDL goals 30 points higher. It also swapped in a new risk calculator, asks every adult to test Lp(a) once, prefers newer math for LDL, and recommends against supplements for cholesterol.
What we’d do
If you last talked about cholesterol with a doctor before March 2026, bring three questions to your next visit: what’s my 10-year risk on PREVENT, which LDL goal does that give me, and have I had Lp(a) tested? Then hold your own panel against that goal.
If you take a cholesterol medicine, keep taking it. A new guideline doesn’t change your prescription by itself, and your prescriber decides any start, stop or change.
If you remember three things
- Goals are back. LDL under 100, 70 or 55 mg/dL by your risk, where the 2018 guideline had none.
- Your risk comes from a new calculator. The old one overestimated 10-year risk by 40 to 50%.
- Earlier counts. The guideline’s first message is to treat earlier, to cut a lifetime of exposure.
Why people are confused
Search for “what should my LDL be” and you’ll still find pages written for the 2018 guideline, which set no LDL goals at all, beside lab sheets that print one range for everyone. Plenty of people hear from a friend or a news story that “the cholesterol guidelines changed” and don’t know whether it means them. If you’ve ever had a cholesterol test, it probably does.
The new guideline came from the American College of Cardiology, the American Heart Association and nine other groups, and it’s the first full rewrite since 2018. Roger Blumenthal, who chaired it, said doctors should now think about medicine “earlier than we would have considered 10 years ago”.
The old rule beside the new one
The guideline prints its own table of what’s new. These are the changes that touch most people, with the 2018 rule beside each.
| 2018 | 2026 | |
|---|---|---|
| LDL goals | None. A statin was judged by how much it cut LDL (50% or more at high intensity), and 70 mg/dL was the line to consider a second drug for people with heart disease at very high risk | Goals are back: under 100 at borderline or intermediate risk, under 70 at high risk, under 55 for most people who’ve had a heart attack or stroke. The percentage cut still counts too |
| Non-HDL goals | None | 30 points above the LDL goal: under 130, 100 or 85 |
| Your risk | The Pooled Cohort Equations, a 10-year risk with lines at 7.5% and 20% | PREVENT, for ages 30 to 79, with 10 and 30-year risk. Low is under 3%, borderline 3 to under 5%, intermediate 5 to under 10%, high 10% or more |
| Lp(a) | A risk enhancer at 50 mg/dL (125 nmol/L) or more, if someone measured it | Test every adult at least once. 125 nmol/L or more is about 1.4 times the risk, 250 or more at least double |
| How LDL is worked out | A direct LDL or a newer estimate was reasonable only when LDL was under 70 | The Martin/Hopkins or Sampson/NIH equation is preferred over the 1972 Friedewald formula, for everyone |
| ApoB | No recommendation of its own | Reasonable for people on treatment once LDL and non-HDL goals are met, above all with high triglycerides or diabetes |
| Supplements | No recommendation | Not recommended to lower LDL or triglycerides |
| Coronary calcium scan | Reasonable when a statin decision is uncertain | Should be used when the decision is uncertain. Any calcium supports starting treatment and an LDL goal under 100 |
The goals came back
The 2018 guideline had no number goals for LDL. It told doctors to judge a statin by the share of LDL it took off. The 2026 guideline keeps that share and adds the numbers back, so you can hold your own result against a line.
| Which fits you | LDL goal | Non-HDL goal |
|---|---|---|
| Heart attack, stroke, stent or bypass | under 55 mg/dL1.4 mmol/L, or under 70 (1.8) if your doctor says you're not at very high risk | under 85 mg/dL2.2 mmol/L, or under 100 (2.6) if your doctor says you're not at very high risk |
| Diabetes, ages 40 to 75 | under 100 mg/dL2.6 mmol/L, or under 70 (1.8) if your doctor puts your 10-year risk over 10% | under 130 mg/dL3.4 mmol/L, or under 100 (2.6) if your doctor puts your 10-year risk over 10% |
| High 10-year risk (10% or more) | under 70 mg/dL1.8 mmol/L | under 100 mg/dL2.6 mmol/L |
| Borderline or intermediate risk (3 to under 10%) | under 100 mg/dL2.6 mmol/L | under 130 mg/dL3.4 mmol/L |
| Low risk (under 3%) | No number goal, healthy habits | No number goal, healthy habits |
From the 2026 ACC/AHA guideline, with the low-risk and diabetes rows as Labcorp's summary sets them out. An LDL of 190 or more is a doctor visit at any risk.
At low risk there’s still no number goal, just healthy habits, unless your LDL is 160 to 189 or your 30-year risk is 10% or more. There, a moderate statin is “reasonable to reduce cumulative exposure to atherogenic lipoproteins”, which is the guideline’s way of saying LDL times years. What should my LDL be? goes through each band.
A new risk calculator
The goal you get depends on your 10-year risk, and that number now comes from PREVENT, an American Heart Association calculator for adults 30 to 79 with an LDL of 70 to 189. The old Pooled Cohort Equations overestimated risk by 40 to 50%, the guideline’s chair said, so a risk worked out before 2026 doesn’t compare with a new one. Ask for your PREVENT number by name.
At borderline risk (3 to under 5%), a statin can be considered. At intermediate risk (5 to under 10%), it should be considered after a talk with your doctor. Things the calculator doesn’t count can tip the decision toward treatment: a family history of early heart disease, an Lp(a) of 125 nmol/L or more, menopause before 45, or preeclampsia, diabetes or high blood pressure in a pregnancy.
Lp(a) for everyone, once
Lp(a) is an inherited particle that food barely moves, and it’s high in about 1 in 5 people. The 2026 guideline asks every adult to have it measured at least once. Since it hardly changes, once is usually enough. What is Lp(a)? has the numbers.
Better math for LDL
On most panels, LDL is calculated from your total, HDL and triglycerides. Since 1972 most labs used the Friedewald formula, which assumes a fifth of your triglycerides is cholesterol in other particles. In 1.35 million real panels that share ran from about 1 in 4.5 to 1 in 6 for the middle half, so the formula slips when triglycerides are high or LDL is low. The guideline now prefers two newer equations, Martin/Hopkins (2013) and Sampson/NIH (2020). Which LDL is right? shows them side by side on your numbers.
No supplements
For the first time the guideline gives supplements a recommendation of their own, and it says they’re not recommended to lower LDL or triglycerides. In the SPORT trial in 2023, six best sellers (fish oil, cinnamon, garlic, turmeric, plant sterols and red yeast rice) didn’t lower LDL more than a sugar pill over 28 days, and a 5 mg statin took it down 35%. Do cholesterol supplements work?
Starting earlier
The guideline’s first take-home message is to treat earlier, to cut a lifetime of exposure. It wants advice on health habits to start in youth, a lipid test for every child once between 9 and 11, a test for every adult from 19 and at least every 5 years after, and medicine considered in young adults with an LDL of 160 or more or a strong family history of early heart disease. Am I too young to worry about cholesterol? and why LDL is a lifetime number have the reasons.
What stayed the same
An LDL of 190 or more is still a doctor visit at any risk, and the guideline now adds that genetic testing for FH can be useful there. Triglycerides of 500 or more still put your pancreas at risk, and 1000 or more especially. Statins are still the medicine the guideline turns to first, and food changes still go with every plan. When medicine is the conversation to have has the lines.
What to ask at your next visit
- What’s my 10-year risk on PREVENT, and which band does it put me in?
- Which LDL and non-HDL goals does that give me?
- Which equation did the lab use for my LDL, and should we use non-HDL or ApoB instead?
- Have I had Lp(a) tested?
- Do my family history, my pregnancies or an early menopause change my band?
Take your last two panels with you. Is my cholesterol bad? holds your numbers against every band before you go.
If you take a cholesterol medicine, your prescriber sets your goal and decides any start, stop or change. Keep taking it, and bring your questions to them.
7 sources
- Blumenthal RS, Morris PB, Gaudino M and others, 2026 ACC/AHA/AACVPR/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of dyslipidemia, JACC and Circulation, 13 March 2026doi.org
- The same guideline, full text with its Top Take-Home Messages and Table 1 (What Is New), Circulation, 2026api.iscpcardio.org
- American College of Cardiology, ACC/AHA issue updated guideline for managing lipids, cholesterol, press release, 13 March 2026acc.org
- Labcorp, 2026 ACC/AHA dyslipidemia guideline updatelabcorp.com
- Grundy SM, Stone NJ and others, 2018 AHA/ACC guideline on the management of blood cholesterol, Circulation, 2019pmc.ncbi.nlm.nih.gov
- Laffin LJ and others, Comparative effects of low-dose rosuvastatin, placebo, and dietary supplements on lipids and inflammatory biomarkers (SPORT), JACC, 2023pubmed.ncbi.nlm.nih.gov
- Martin SS and others, Comparison of a novel method vs the Friedewald equation for estimating low-density lipoprotein cholesterol levels from the standard lipid profile, JAMA, 2013pubmed.ncbi.nlm.nih.gov
