2026 Cholesterol Guidelines and What Clinicians Need to Know

Podcast Transcript

Announcer:

Welcome to Cardiac Consult, brought to you by the Sydell and Arnold Miller Family Heart, Vascular & Thoracic Institute at Cleveland Clinic. This podcast will explore the latest innovations, medical and surgical treatments, diagnostic testing, research, technology and practice improvements.

Dr. Ashish Sarraju:

Thank you for joining us. I'm Dr. Ashish Sarraju. I'm a preventive cardiologist here in the Section of Preventive Cardiology and Rehabilitation at the Cleveland Clinic main campus in Cleveland, Ohio. I am the Director of the Center for Inherited Lipid Disorders and the Director of Research for Preventive Cardiology. We are joined today by Dr. Leslie Cho. Dr. Cho, could you please introduce yourself?

Dr. Leslie Cho:

Thank you. My name is Leslie Cho. I'm the Section Head for Preventive Cardiology and the Vice Chair for HVTI.

Dr. Ashish Sarraju:

Wonderful. We're here to have a conversation about really breaking news in the world of preventive cardiology. That is the 2026 ACC/AHA guidelines for the management of cholesterol, a timely and much-needed update from the prior guidelines more than 10 years ago. Let's start off. Big picture, these guidelines are perhaps the most generalizable guidelines to clinicians, even outside of cardiology. A lot of eyes are going to be on these guidelines and on how to operationalize them. Big picture, what do clinicians need to know about what's new about these guidelines and how it should change what they've been doing for cholesterol management?

Dr. Leslie Cho:

It's a great question and a complex question too, because I think as a clinician, one of the most important things is that you have to check LDL. We now recommend checking LDL much earlier, starting at age 19. Obviously, the pediatricians recommend their own thing at nine to 11, but as an adult, 19 and every five years thereafter. Then using the risk calculator, the new PREVENT ASCVD risk calculator, to assess 10-year and 30-year risk to start therapy if they need to.

Dr. Leslie Cho:

Then, goals are back. Goals are back instead of the percentage. Who knows what that percentage meant? The goals are back and I think using less than 100 for primary prevention, less than 70 for moderate risk, and then very high risk is less than 55.

Dr. Ashish Sarraju:

That's great news. Tell us a little bit more about lipoprotein(a). That's in the guidelines, of course. Who should get that?

Dr. Leslie Cho:

So, the guideline is sort of revolutionary in that it finally, for the first time, recommends that everyone should get Lp(a) checked at least once in their lifetime. I think it is very important and very apt. It is a causal risk factor for ASCVD as well as calcific aortic stenosis. Who knows what the Lp(a) trials will show, but if your Lp(a) is high, if it's greater than 150 nanomoles per liter or 125 nanomoles per liter, you have a 1.4-fold increased risk. Really, optimizing their LDL is super important.

Dr. Ashish Sarraju:

So, what do you say to clinicians who may say, "Well, why am I checking Lp(a) if there are no medications for it? It's going to cause me anxiety and increase our workload."

Dr. Leslie Cho:

We check it so that you can modify other risk factors that you can control, like high blood pressure, like cholesterol. It is critically important to control your blood pressure if your Lp(a) is high. It is critically important to get your LDL to less than 70. If your Lp(a) is super high, then start aspirin, because we know from two different studies that that's helpful.

Dr. Ashish Sarraju:

Right. Okay. Really, controlling the other risk factors to mitigate any excess risk is critically important. Lp(a) is actionable. There's no doubt about that.

Dr. Leslie Cho:

There's no doubt about the actionability of Lp(a).

Dr. Ashish Sarraju:

Great. The PREVENT calculator is also new. We used to use the pooled cohort equations to decide how to allocate statin therapy and preventative therapies. What should clinicians know about why to use the PREVENT calculator and how is it different from the pooled cohort equations?

Dr. Leslie Cho:

The PREVENT risk calculator was studied in many more patients and validated in even more patients than the pooled cohort equation. It's actually much more refined. About a million patients are less likely to get on statins based on the PREVENT calculator than the pooled cohort equation. The pooled cohort equation overestimated the risk. The PREVENT risk calculator includes kidney function. It includes things like your ZIP code.

Dr. Leslie Cho:

It actually has lots of other things that are, I think, critically important. We know that CKM, that kidney metabolic syndrome, is so critically important to inflammation and developing ASCVD. The PREVENT calculator, I know it's cumbersome for clinicians. Hopefully it will become part of EMR so that it's easy to do, so that it's not more burden for our poor clinicians.

Dr. Ashish Sarraju:

Right, right. In terms of actions, right, what should clinicians do to treat cholesterol that's maybe different from what we've been doing, what the older guidelines suggested? You mentioned goals are back, right? So that's one. What about younger patients?

Dr. Leslie Cho:

Yeah. I mean, I think it makes a very important philosophical change, which is the lifetime burden of atherogenic particles and treating and managing that. If you're greater than age 30 and your LDL is greater than 160, it recommends treatment, which is very different. Do you remember the greater than 40, greater than LDL of 190 in the previous guidelines? I think if you're younger patient, getting some of the novel risk markers like Lp(a), CRP, if you're Southeast Asian or Filipino, if you've had reproductive adverse outcome, all of those things become critically important on who gets started on medications or who gets started on even lifestyle counseling, which everybody should actually get that counseling.

Dr. Leslie Cho:

To your interest in inherited disorders, one in 250 have FH (familial hypercholesterolemia), and it's important to identify those patients. Those patients, if we get them when they're young, we really help them, really prevent them from having ischemic cardiomyopathy. How do you think of it? How do you think of young patients?

Dr. Ashish Sarraju:

Yeah. I think age is, as we know, a very strong risk factor for heart disease. But I think, as you and I both know, our blood cholesterol levels aren't just modulated by what we eat or how much we exercise. Genetics plays a very big role. There are a lot of people out there for whom lifestyle modification for cholesterol management is very appropriate, and that may be the majority of patients. But there are a lot of folks out there in whom, if we don't recognize their inherited lipid disorders early and don't start them on treatment, we're undertreating their risk, which is a bit of a shame because I see FH and inherited lipid disorders as some of the most treatable entities we have in cardiology.

Dr. Ashish Sarraju:

It's one of the few conditions where if you pull the levers hard enough and strong enough early enough, you can nearly mitigate their lifetime risk. That early diagnosis is great. I think these guidelines are trending towards that, right? Basically saying, look earlier, don't dismiss risk based on age, “look at the whole picture” kind of thing. Of course, we have an inherited lipid disorder center in our section, as do many other places, I'm sure. What a great move by the guidelines to do this.

Dr. Ashish Sarraju:

Are there any new trials in Lp(a) management or lipid management that clinicians should look out for over the next year or two?

Dr. Leslie Cho:

Well, I mean, we eagerly await the phase three study for Lp(a)HORIZON, which will be the first to come out for Lp(a) treatment in patients after myocardial infarction. Then will come the OCEAN(a), which is the siRNA trial for people with MI, but also with stents and bypasses. Then we'll come sort of the high-risk studies or high risk but not acute, which is the Lilly trial with phase three.

Dr. Leslie Cho:

I mean, this is an exciting time to be in the cholesterol field because rarely do you have sort of paradigm shift treatments coming up, and we have so many on the horizon. You have been involved with gene editing, so you know of all the cutting edge, that's probably the most cutting-edge of our cholesterol trials to come out. I think the important thing in 2026 is that yes, use statins, but once you have reached statins, you have so many new ways now to treat with all the non-statins, PCSK9, ezetimibe, bempedoic acid plus ezetimibe. There are so many things to get patients to goal. There really is no reason why people can't get to goal.

Dr. Ashish Sarraju:

Right. That's a really great way of putting it. The emphasis is not on this mindset of, “did I prescribe a statin”? I guess it's more on “let's find a way to get you to goal”. Even if there are side effects or hesitation sometimes, which is a real vexing issue, but it's there. This idea of LDL goals and trying to get to goals and all these other options makes a lot of sense as a paradigm shift as opposed to starting a medication and sort of forgetting about it and then we sort of run the risk of non-adherence or not reaching lipid goals and things like that.

Dr. Leslie Cho:

If there's one message I want to say to the clinician is that these guidelines I hope will be able to provide them with an easy way to think about how to treat and how to mitigate risk. Really, that target of 55, that target of 70, that target of 100 really has a lot of evidence. Sometimes we think as a clinician think, “oh, there's 79”. It really does matter. It really does matter.

Dr. Ashish Sarraju:

That's a great final take-home message there for our clinicians: reading the guidelines and paying close attention to the numbers. Thank you, everybody, for joining us for this podcast.

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