New cholesterol guidelines: Preventing heart disease by starting earlier in life
July 8, 2026
Most people have some understanding of cholesterol, and they know having too much of it is not healthy.
Having high cholesterol is a major cause of heart attacks and stroke, and it contributes to heart disease – the leading causes of death in the U.S. But not all types of cholesterol are the same, and most cardiovascular problems related to cholesterol are both preventable and manageable.
In March 2026, the American College of Cardiology (ACC), the American Heart Association, and nine other medical associations jointly published new guidelines for managing cholesterol. UT Southwestern cardiologists Ann Marie Navar, M.D., Ph.D., Anand Rohatgi, M.D., and I contributed to these guidelines – the first cholesterol guidelines update since 2018.
The new guidelines change how we approach the prevention and management of high cholesterol in several key ways:
- Earlier prevention
- Personalized cholesterol goals
- More testing tools to refine risk
- More treatment options beyond statins
Starting preventive steps against high cholesterol early in life can lead to better outcomes – including for people with a genetic propensity for the disease. The first step is to understand what high cholesterol is and how to determine your personal risk of cardiovascular problems.
What is high cholesterol?
Cholesterol is a waxy substance your body uses to build cells and hormones. It has an important role to play in your body’s systems, but too much of certain types can contribute to plaque buildup in the arteries over time. That is known as atherosclerosis.
Total cholesterol is the combined amount of cholesterol from several particles in the blood, including high-density lipoprotein (HDL) and low-density lipoprotein (LDL) cholesterol:
- LDL is known as “bad cholesterol” because it can deposit cholesterol into artery walls. Over time, that plaque buildup may narrow arteries and increase the risk of heart attack or stroke by rupturing and triggering a blood clot to form in the artery.
- HDL is called “good cholesterol” because it helps carry excess cholesterol away from the bloodstream and back to the liver, where it can be processed and removed. Higher HDL levels are generally associated with better heart health.
- Triglycerides are the most common type of cholesterol in the body. Your liver and small intestine form triglycerides from your food, and your body uses them to store energy in your fat cells. High triglyceride levels are generally associated with higher risk of heart disease and stroke.
For most adults, it is reasonable to aim for an LDL of less than 100 mg/dL. This can typically be achieved through a combination of diet, exercise, and medication. Your optimal levels may be different depending on your lifestyle, overall health, genetics, and family heart-health history. If there is significant plaque in your arteries, we target LDL cholesterol less than 70 mg/dL. If you have a history of heart attack or stroke, we target an LDL cholesterol less than 55 mg/dL.
About 20% of people have a high lipoprotein(a), or Lp(a), a genetically inherited particle that can increase the risk of heart disease, stroke, and aortic valve disease. Every person should be screened for Lp(a) at least once in adulthood to determine their risk of atherosclerosis. This is a test we specifically have to order separately from the usual cholesterol profile.
Another inherited condition, familial hypercholesterolemia (FH) causes very high LDL cholesterol levels from birth that cause premature heart disease. About 1 in 250-300 people in the U.S. have FH. Many are undiagnosed. The new guidelines recommend that all children with a family member who had premature atherosclerosis (before age 50) should be screened for FH after age 2 by checking their cholesterol profile.
Early prevention is key to cholesterol management
Atherosclerotic plaque often develops long before symptoms appear, which is why early prevention matters. Many younger adults feel healthy and may not realize their cholesterol levels or other risk factors are putting them on a path toward future cardiovascular disease.
Risk of heart disease, heart attack, and stroke rises when people have high cholesterol but can be accelerated in the presence of other cardiovascular risk factors such as:
- Diabetes
- Smoking
- Poor nutrition
- Physical inactivity
- Excess weight
- High blood pressure
- Family history of heart attack or stroke before age 50
Fortunately, our prevention tools are improving. Doctors can now look beyond a traditional 10-year risk estimate and use 30-year or lifetime risk projections to better understand who may face problems later in life. That means younger adults can have more meaningful conversations with their doctors about long-term prevention, even if their short-term risk seems low today.
How is high cholesterol diagnosed?
High cholesterol is usually diagnosed with a blood test called a lipid panel. This common screening test measures total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides. Doctors review these results together rather than focusing on just one number because each measurement can offer different insights about heart and blood vessel health.
Testing for high cholesterol often measures LDL-C, which refers to the amount of cholesterol carried inside LDL particles. LDL-C is one of the main targets of treatment because lowering it has been shown to reduce cardiovascular risk. However, the new guidelines acknowledge that LDL alone does not always tell the full story.
ApoB testing
In some cases, your doctor may recommend an ApoB test. ApoB is a protein found on the surface of many harmful cholesterol particles that can enter artery walls, including LDL and other potentially “bad” lipoproteins. Because ApoB reflects the number of these particles, not just how much cholesterol they carry, it can sometimes give a clearer picture of cardiovascular risk, especially when standard cholesterol results seem mixed or unclear.
Lp(a) testing
Lp(a) is largely determined by genetics and is not routinely measured on a standard lipid panel. We now recommend that every adult ask their doctor about Lp(a) testing once in their lifetime to understand their risk of cardiovascular disease.
If testing shows elevated cholesterol or other risk factors, the next step is to see a doctor for a personalized treatment plan.
Related: Read “Four people who should see a preventive cardiologist”
Advancing heart health
UT Southwestern has been at the forefront of cholesterol research for decades, with discoveries that continue to benefit patients today.
- In 1985, Drs. Michael Brown and Joseph Goldstein were awarded the Nobel Prize for identifying how the body regulates LDL, or “bad” cholesterol. Their work led to the development of statins, medications that have become a cornerstone of heart disease prevention.
- As part of the Dallas Heart Study, which UTSW launched in 2000, Helen Hobbs, M.D., and her research colleague, Jonathan Cohen, Ph.D., found mutations in the PCSK9 gene that were linked to extremely low cholesterol levels. This discovery led to a new class of drugs that lower LDL cholesterol by targeting the PCSK9 gene.
What are the treatments for high cholesterol?
Treatment for high cholesterol and related conditions is not one-size-fits-all. For many people, the first step is improving habits that affect heart health, including:
- Nutrition: A heart-healthy diet such as the Mediterranean diet, which focuses on plant-based eating and lean proteins, can help lower LDL cholesterol.
- Exercise: Aerobic exercise can increase levels of HDL cholesterol, which transports excess cholesterol from your arteries to your liver.
- Weight management: Maintaining a healthy weight positively influences the metabolic processes that in turn influence how much cholesterol your body creates.
- Avoiding tobacco: Smoking lowers HDL cholesterol, diminishing your body’s ability to reduce plaque buildup in your arteries. It can also damage your artery walls.
Statins
When lifestyle changes are not enough, many patients benefit from statins. Statins are a medication that reduces the amount of cholesterol the liver makes, triggering the liver to take more LDL particles out of the bloodstream.
Statins are among the most studied medications, with decades of evidence showing they lower the risk of heart attack and stroke. Like all medications, statins can have side effects for some people. Most can be managed by adjusting the dose, trying a different statin, or using another treatment option in partnership with a doctor.
Related: Read “10 facts about statins and high cholesterol”
PCSK9 inhibitors
PCSK9 inhibitors are an advanced medication to help the liver clear LDL cholesterol more efficiently by blocking PCSK9, a protein that interferes with LDL receptors. Clinical trials have shown that PCSK9 inhibitors added to statins can significantly lower LDL cholesterol and reduce heart attack and stroke risk, especially in patients who are at higher risk.
Ongoing research for Lp(a) treatment
There is not yet a widely used medication specifically approved to lower Lp(a), though promising therapies are being studied in clinical trials. In the meantime, the best strategy is to manage the heart attack and stroke risk factors through lifestyle changes and proven medications that lower overall cardiovascular risk.
Keep in mind that your care plan can be adjusted over time. If one approach is not working well or causes side effects, or if your risk changes, your doctor can help revise the plan. There are more cholesterol management options today than ever before, and treatment can be tailored to your health needs and goals.
If you have high cholesterol or a personal or family history of heart disease, talk with a doctor about steps to control your risk factors. With a personalized plan, you can start on an effective path to prevent a heart attack or stroke.
To talk with an expert about cholesterol management, make an appointment by calling 214-645-8000 or request an appointment online.
