Cholesterol control gets personalized – a cardiologist explains how new guidelines tailor treatment to your unique risk profile

High cholesterol, or dyslipidemia, affects at least 25% of Americans. It occurs when there are excessive levels of cholesterol or fatty acids in the blood. Cholesterol is a waxy substance needed for cell function, but too much can lead to atherosclerotic cardiovascular disease (ASCVD), a group of conditions caused by plaque buildup in arteries. This buildup narrows blood vessels, reducing blood flow to vital organs like the heart and brain. Over time, ASCVD can cause heart attacks or strokes. The condition develops gradually, often over decades, making early detection and management critical. ASCVD is a leading cause of death worldwide, and its risk increases with factors like poor diet, lack of exercise, smoking, and conditions such as diabetes or high blood pressure.

In March 2026, the American Heart Association and the American College of Cardiology updated their guidelines for treating high cholesterol, last revised in 2018. These guidelines introduce a more proactive approach, emphasizing earlier and more aggressive treatment to reduce ASCVD risk over a lifetime. The update is based on research showing that the longer high cholesterol persists, the higher the risk of cardiovascular disease. The guidelines provide doctors with tools to assess individual risk more accurately, including advanced blood tests and imaging. They also encourage the use of the PREVENT-ASCVD calculator, which estimates a patient’s 10-year and 30-year risk of cardiovascular disease using factors like body mass index, blood pressure, diabetes history, kidney function, and smoking status.

The 2026 guidelines highlight several blood tests to better predict cardiovascular risk. Traditional tests like LDL (low-density lipoprotein, or “bad” cholesterol) and HDL (high-density lipoprotein, or “good” cholesterol) remain important. However, the guidelines now emphasize two newer markers: apolipoprotein B (ApoB) and lipoprotein A (LpA). ApoB measures the number of plaque-forming particles in the blood, which may be a more accurate predictor of risk than LDL alone, especially for patients with diabetes or metabolic syndrome. LpA is a sticky molecule similar to LDL but with a higher tendency to cause artery blockages. Elevated LpA levels increase lifetime cardiovascular risk. The guidelines recommend checking LpA once in all adults. Another key test is the coronary artery calcium (CAC) score, obtained via a CT scan, which measures calcium deposits in heart arteries. Higher CAC scores indicate greater risk.

The new guidelines introduce a CPR model to personalize cholesterol management: Calculate a patient’s 10-year cardiovascular risk using tools like PREVENT-ASCVD, Personalize the estimate by considering additional factors such as family history and lab results, Reclassify risk using imaging like CAC scores, and Reassess treatment based on the updated information. This approach ensures that treatment plans are tailored to each patient’s unique risk profile. For example, a patient with a high CAC score may require more aggressive medication, while someone with low risk might focus on lifestyle changes. The goal is to prevent ASCVD by addressing risk factors early and continuously adjusting care.

The guidelines recommend starting cholesterol screening early in life. Children aged 9 to 11 should have their cholesterol levels checked to identify any abnormalities. Adults aged 19 and older should have cholesterol levels tested every five years. For those at higher risk, screening may begin at age 30, and medication could be considered if necessary. This early detection strategy aims to identify issues before plaque buildup causes significant damage. The guidelines also recommend specific lifestyle changes to reduce risk, such as reducing sugar, refined carbohydrates, saturated fats, and alcohol intake. Routine exercise is encouraged, with a target of 150 minutes of moderate activity or 75 minutes of vigorous activity per week, plus two days of resistance training. Weight loss of 5% to 10% is advised for overweight or obese individuals.