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2026 Cholesterol Guidelines: What They Say
Many studies are happening worldwide on how to manage cholesterol, and doctors are also saying many different things; we see some difference of opinion. At the same time, WhatsApp messages are coming saying do not use cholesterol medicines at all, they are dangerous. Keeping all this in view, the American Heart Association and the American College of Cardiology, with some other institutes, released new lipid guidelines in 2026. Understanding that not only cholesterol but other lipids are also important, they released guidelines covering them. From now on, treatment needs to be given according to these 2026 guidelines.
What we must notice here is that these are American guidelines, made for American people, based on studies done in American people. Guidelines made in India are even stricter: we should use more tablets and take cholesterol to even lower levels, because the risk in India is higher. So whatever I tell you is new in these guidelines, Indian guidelines are a little stricter still. The Lipid Association of India guidelines may be even stricter.
The previous guidelines came in 2018, and now they have come in 2026. We learn very important things from them. Watch carefully, and if you have doctor friends, show them too.
How risk is calculated
In 2018, risk was estimated with the Pooled Cohort Equations. Now there is the PREVENT ASCVD risk calculator, available on the app store, and risk should be calculated with it. Risk categories are clearly defined:
- Low risk: the chance of a heart problem in the next 10 years is less than 3%.
- Borderline risk: 3 to 5% in the next 10 years.
- Intermediate risk: 5 to 10% in the next 10 years.
- High risk: more than 10%.
These apps are available, and risk should be checked with them.
LDL targets
In 2018, LDL targets were given as percentage reduction: LDL should fall by more than 50%. Now in 2026, along with percentage reduction, they also give absolute reduction, how carefully to reduce it.
In 2018, for people with somewhat high risk, for example those who had a bypass or a stent, LDL below 70 mg was enough. In 2026 they say that for high-risk and very high-risk people, those who already had a problem and may get a problem again, cholesterol, meaning LDL levels, should be reduced below 55 mg per decilitre.
Along with this they also give non-HDL targets. After you control LDL, check non-HDL levels and control them too, and then check ApoB levels and control those as well.
Statins earlier
Now, more than before, they say start statins early. Until now we were told that in young adults there is no need for tablets for primary prevention until LDL crosses 190. In 2026, in young adults we should start tablets if LDL crosses 160. Along with this, start them if there is a strong family history.
For people between 40 and 75 years, they say start statins whatever the LDL. For whom? People with diabetes, people with kidney problems in stage 3 or stage 4, and people with HIV. For these people between 40 and 75, do not look at how much LDL there is; start a statin.
Lp(a)
Another important thing, not in 2018 but in 2026, is called Lp(a), lipoprotein little a. We have been getting it done outside, but it has come into the guidelines for the first time. All adults should check Lp(a) at some point in their life. Check it once; there is no need to follow it up again. Now many people with high Lp(a) are doing Lp(a) every year to see whether it has come down. There is no need to check it like that.
ApoB is for residual risk: for example, someone had a heart attack and LDL is low. Such people are told to check ApoB to see whether there is risk because of it.
CT calcium score
They also spoke about the CT calcium score and gave it a Class 1 recommendation. When the question is whether to use a statin, a cholesterol tablet, or not, they say check the calcium score if there is doubt:
- Zero: if calcium is not there at all and the other risk is not high, a statin is not needed.
- Up to 100: a statin may be used or may not be used.
- Above 100: definitely use it.
- Above 300: definitely use it aggressively.
Primary prevention algorithm and screening
The primary prevention algorithm is explained very clearly. This is something we must understand well:
- From age 19 onwards, check cholesterol once every five years, the new guidelines say.
- At 9 to 11 years of age, do the first lipid profile for everyone. Why? In heterozygous familial hypercholesterolaemia, family-related high cholesterol, the levels may be present in children even if the parents do not have them, and we cannot see it. So in all children uniformly, whether there is a family history or not, check cholesterol levels once between 9 and 11 years. This is a very latest guideline, a sweeping one. It says test them; it does not mean start treatment at nine years. But if levels are very high, starting from a young age reduces the chance of heart problems due to cholesterol levels.
New medicines
New medicines have been included to some extent in these guidelines: bempedoic acid; ezetimibe, which was already there; inclisiran; if still not reduced, evinacumab; and the PCSK9 injections now available. The guidelines say they can be used if it does not reduce with a statin. If levels are very high, give aggressive treatment with combination therapy.
Along with cholesterol levels, triglyceride levels also need to be checked, because heart disease can come from triglycerides too. If they cross 1,000, there is a new medicine called olezarsen. It is a new type of molecule, an ApoC3 inhibitor. It has been approved in America, but not yet in India; it may come this year. For people with very high triglycerides, use olezarsen.
No dietary supplements, and genetic testing
Another important thing said in 2026: do not use dietary supplements to reduce cholesterol. It is clearly said. It is not specifically known that cholesterol levels fall with any dietary supplement, so we definitely should not use them.
For familial hypercholesterolaemia, cholesterol running in the family, they also say to get genetic testing done.
The CPR strategy
Guidelines have become more aggressive and more personal. They now use a strategy called CPR: first Calculate how much the risk is and identify it; then, using PREVENT, Personalise it, meaning along with the calculated risk, check whether the person has anything else not included in it that increases risk; then Reassess. This is called the CPR strategy.
In summary
- Test earlier: at 9 to 11 years, but not regularly.
- From 19 years, check cholesterol every five years.
- If LDL crosses 160, start a statin even for primary prevention.
In any case, setting aside everything we had earlier about when and how to use cholesterol medicines, a new set of guidelines was released in 2026. Learn about it fully, and watch the video again and again if you want; it has factual data. Based on it, consult your doctor and see how you should take cholesterol medicine. Do not suddenly stop cholesterol medicines; everyone should know that is a somewhat dangerous thing.
In his words: the key point
The 2026 guidelines are more aggressive and more personal. Consult your doctor about your cholesterol medicine, and do not suddenly stop cholesterol medicines.
Frequently asked questions
What is the new LDL target in the 2026 guidelines?
Dr. Mukharjee explains that for high- and very high-risk people, those who already had a problem and may get it again, LDL should be reduced below 55 mg/dL. In 2018 it was below 70.
When should young adults start a statin?
According to the 2026 guidelines, when LDL crosses 160 (earlier 190), or when there is a strong family history.
How often should Lp(a) be tested?
Once in life for all adults. There is no need to repeat it every year.
Should children get a cholesterol test?
Yes, once between 9 and 11 years for all children, to detect familial high cholesterol. Testing does not mean starting treatment.
— Dr. M. S. S. Mukharjee
Senior Interventional Cardiologist
Pulse Heart Super Speciality Hospital, Miyapur, Hyderabad
This article is for educational purposes only and isn't a substitute for individualised medical advice. Talk to your own doctor before starting, stopping or changing any medicine.