ACC / AHA · 2026

Dyslipidemia — Management Guideline

Source: 2026 ACC/AHA/AACVPR/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Dyslipidemia

✓ Edition checked 3 Oct 2026 — ACC / AHA 2026 is the current edition as of this date.

Guideline: Strong Guideline: Conditional Guideline: Not recommended ClinicoQ pathway suggestion (not from the cited guideline)

Diagnosis

Diagnostic criteria Dyslipidemia is identified from a fasting or non-fasting lipid panel (total cholesterol, LDL-C, HDL-C, triglycerides, non-HDL-C), with apoB and lipoprotein(a) as additional tests. Management is guided by risk: PREVENT-ASCVD 10-year risk (and 30-year risk in younger adults) in people aged 30-79 years without ASCVD and with LDL-C 70-189 mg/dL; clinical ASCVD (acute coronary syndrome, MI, stable or unstable angina, coronary or other arterial revascularization, stroke, TIA, or peripheral artery disease) is managed by event risk. Very high risk means two or more major ASCVD events (ACS within the past 12 months, prior MI, prior ischemic stroke, symptomatic PAD), or one major event plus multiple high-risk conditions (age over 65 years, prior coronary revascularization, current smoking, diabetes, history of heart failure, hypertension, or LDL-C above 100 mg/dL despite maximally tolerated statin plus ezetimibe).

⚠ Alarm features (investigate before diagnosing)

LDL-C of 190 mg/dL or above (severe hypercholesterolemia; consider familial hypercholesterolemia)
Very high triglycerides (consider causes and pancreatitis risk)
Premature ASCVD or a strong family history
Lipoprotein(a) of 125 nmol/L (50 mg/dL) or above

Initial workup

Test	When to order
Lipid panel (LDL-C, non-HDL-C, HDL-C, triglycerides)	Baseline assessment and monitoring of response to lipid-lowering therapy.
PREVENT-ASCVD risk estimate	Adults aged 30-79 years without ASCVD or subclinical atherosclerosis and with LDL-C 70-189 mg/dL: low below 3%, borderline 3% to below 5%, intermediate 5% to below 10%, high 10% or above.
Lipoprotein(a)	Measured at least once in adulthood; 125 nmol/L (50 mg/dL) or above indicates increased ASCVD risk.
Coronary artery calcium score	To refine risk in selected primary prevention patients; a score of 300-999 AU supports a stricter LDL-C goal below 55 mg/dL.

Decision Points

❓ Does the patient have clinical ASCVD?

No clinical ASCVD (primary prevention) → Primary prevention (no clinical ASCVD)

Clinical ASCVD, not at very high risk → Clinical ASCVD, not at very high risk

Clinical ASCVD at very high risk (multiple major events, or one major event plus multiple high-risk conditions) → Clinical ASCVD at very high risk

❓ Are triglycerides persistently 150-499 mg/dL despite maximally tolerated statin therapy?

Yes, TG 150-499 mg/dL → Hypertriglyceridemia (TG 150-499 mg/dL)

No, continue the pathway for the patient's risk group → Primary prevention (no clinical ASCVD)

Treatment

Primary prevention (no clinical ASCVD)

1 Statin therapy, intensity by PREVENT-ASCVD 10-year risk Guideline recommendation — borderline risk: consider moderate-intensity statin (30-49% LDL-C reduction); intermediate risk: at least moderate-intensity statin, high-intensity at the upper end; high risk: high-intensity statin for 50% or greater LDL-C reduction. Goals: LDL-C below 100 mg/dL (borderline/intermediate), below 70 mg/dL and non-HDL-C below 100 mg/dL (high)

Dose: Moderate intensity (e.g., atorvastatin 10-20 mg or rosuvastatin 5-10 mg) for borderline (3% to below 5%) and intermediate risk; high intensity (e.g., atorvastatin 40-80 mg or rosuvastatin 20-40 mg) for high risk (10% or above) and the upper end of intermediate risk
Duration: Ongoing; recheck lipids after starting or changing therapy
Evidence level: High
Avoid if: Pregnancy or planning pregnancy; active liver disease; prior statin intolerance (see non-statin options)
If no response ClinicoQ pathway: If the LDL-C goal is not reached on the maximally tolerated statin, add ezetimibe

2 Add ezetimibe, then consider a PCSK9 monoclonal antibody or bempedoic acid Guideline recommendation — in high 10-year risk (10% or above) on maximally tolerated statin with or without ezetimibe, adding a PCSK9 monoclonal antibody or bempedoic acid may be reasonable if LDL-C remains 70 mg/dL or above and non-HDL-C 100 mg/dL or above

Dose: Ezetimibe 10 mg once daily; PCSK9 monoclonal antibody and bempedoic acid per product labeling
Duration: Ongoing
Evidence level: Moderate
Avoid if: Known hypersensitivity; bempedoic acid: history of tendon rupture or hyperuricemia/gout (check labeling)
If no response: Inclisiran may be used as an alternative to a PCSK9 monoclonal antibody in severe hypercholesterolemia

3 Severe hypercholesterolemia (LDL-C 190 mg/dL or above) without ASCVD Guideline recommendation — add non-statin therapy if needed to reach LDL-C below 70 mg/dL and non-HDL-C below 100 mg/dL in patients with additional ASCVD risk factors, heterozygous familial hypercholesterolemia, or subclinical atherosclerosis (documented CAC)

Dose: Maximally tolerated statin, then ezetimibe, PCSK9 monoclonal antibody, and/or bempedoic acid; inclisiran is an alternative to a PCSK9 monoclonal antibody
Duration: Ongoing
Evidence level: Moderate
Avoid if: Pregnancy; per individual drug labeling
If no response ClinicoQ pathway: Refer to a lipid specialist if goals are not achieved

Clinical ASCVD, not at very high risk

1 High-intensity or maximally tolerated statin Strong (Guideline recommendation) — aim for at least 50% LDL-C reduction, LDL-C below 70 mg/dL, and non-HDL-C below 100 mg/dL; stricter goals (LDL-C below 55 mg/dL, non-HDL-C below 85 mg/dL) are an option if the patient prefers

Dose: e.g., atorvastatin 40-80 mg or rosuvastatin 20-40 mg once daily
Duration: Ongoing
Evidence level: High
Avoid if: Pregnancy or planning pregnancy; active liver disease
If no response: Add ezetimibe, a PCSK9 monoclonal antibody, or bempedoic acid depending on the degree of LDL-C lowering needed and patient preference

2 Add ezetimibe, a PCSK9 monoclonal antibody, or bempedoic acid Guideline recommendation (reasonable to add) on maximally tolerated statin to reach LDL-C below 70 mg/dL and non-HDL-C below 100 mg/dL

Dose: Ezetimibe 10 mg once daily; PCSK9 monoclonal antibody and bempedoic acid per product labeling
Duration: Ongoing
Evidence level: High
Avoid if: Known hypersensitivity; per individual drug labeling

Clinical ASCVD at very high risk

1 High-intensity statin Strong (Guideline recommendation) — initiate high-intensity statin to achieve 50% or greater LDL-C reduction, with goals of LDL-C below 55 mg/dL and non-HDL-C below 85 mg/dL

Dose: e.g., atorvastatin 40-80 mg or rosuvastatin 20-40 mg once daily, at the maximally tolerated dose
Duration: Ongoing
Evidence level: High
Avoid if: Pregnancy or planning pregnancy; active liver disease
If no response: Add ezetimibe and/or a PCSK9 monoclonal antibody if goals are not reached

2 Add ezetimibe and/or a PCSK9 monoclonal antibody Strong (Guideline recommendation) — should be added on maximally tolerated statin to reach LDL-C below 55 mg/dL and non-HDL-C below 85 mg/dL

Dose: Ezetimibe 10 mg once daily; PCSK9 monoclonal antibody per product labeling (chosen by the LDL-C lowering needed and patient preference)
Duration: Ongoing
Evidence level: High
Avoid if: Known hypersensitivity; per individual drug labeling
If no response: Bempedoic acid may be added if goals are still not met

3 Add bempedoic acid, with or without ezetimibe and/or a PCSK9 monoclonal antibody Guideline recommendation (Class 2a, reasonable) — on maximally tolerated statin to reach LDL-C below 55 mg/dL and non-HDL-C below 85 mg/dL; also applies to a coronary artery calcium score of 300-999 AU

Dose: Per product labeling
Duration: Ongoing
Evidence level: Moderate
Avoid if: History of tendon rupture or hyperuricemia and gout (check labeling); per individual drug labeling
If no response: Inclisiran can replace a PCSK9 antibody when it cannot be tolerated or obtained

4 Inclisiran as an alternative to a PCSK9 monoclonal antibody Guideline recommendation (reasonable) — added to maximally tolerated statin, with or without ezetimibe, in clinical ASCVD at very high risk who cannot tolerate or obtain evolocumab or alirocumab, or who prefer less frequent dosing

Dose: Per product labeling (twice-yearly injection after the initial doses)
Duration: Ongoing
Evidence level: Moderate
Avoid if: Known hypersensitivity; per labeling

Hypertriglyceridemia (TG 150-499 mg/dL)

1 Optimize statin therapy and lifestyle, estimate PREVENT-ASCVD risk if no ASCVD or diabetes Guideline recommendation — statin therapy lowers ASCVD risk in patients with hypertriglyceridemia; routine addition of fibrates or niacin to statin therapy is advised against

Dose: Statin therapy lowers triglycerides by 10-30% in a dose-dependent manner
Duration: Ongoing
Evidence level: High
Avoid if: —
If no response ClinicoQ pathway: Consider icosapent ethyl if the patient has ASCVD, or diabetes with at least one additional risk factor, and LDL-C is below 100 mg/dL on maximally tolerated statin

2 Icosapent ethyl Guideline recommendation (may be considered) — adults aged 50 years or older with ASCVD, or diabetes plus at least one additional risk factor, with TG 150-499 mg/dL, LDL-C below 100 mg/dL, on maximally tolerated statin

Dose: 4 g/day (2 g twice daily)
Duration: Ongoing
Evidence level: Moderate
Avoid if: Fish or shellfish hypersensitivity (check labeling); atrial fibrillation risk

✕ Treatments the guideline advises against

Fibrates or niacin added routinely to statin therapy: The 2026 guideline states that neither is recommended for routine use because of the lack of proven reductions in ASCVD events when added to statin therapy.

⚠️ This is an educational summary of current international clinical practice guidelines and does not replace individualized clinical judgment. Final treatment decisions remain the responsibility of the treating physician.