2026 Cholesterol Guidelines: What Has Changed and What It Means in the UK

In March 2026, the American College of Cardiology and American Heart Association published their first major update to cholesterol management guidelines since 2018. It is a significant document. Although written for clinicians, the thinking behind it is likely to influence how cholesterol risk is assessed and discussed, particularly in private medicine and in more detailed cardiovascular risk assessments.

Here's what's actually changed, why it matters, and what you might want to discuss with your doctor.

One thing to be clear about before we go further. This is an American guideline, written by the American College of Cardiology and the American Heart Association. If you're seen on the NHS, and often in UK private general practice too, your cholesterol is usually assessed and treated with reference to NICE guidance, not the ACC/AHA. The two broadly agree on where things are heading, but they differ on the detail, and some of the changes below are further ahead than current UK practice. I've set out what NICE actually says further down, so you can see where the two line up and where they differ. This article should therefore be read as an explanation of an important international guideline, not as a statement of current NHS policy.

Cholesterol Targets Are Back

The 2018 guidelines focused on reducing your LDL cholesterol by a certain percentage, typically 30–50%, without specifying an actual number to aim for. That approach worked in principle, but in practice it left a lot of patients and clinicians without a clear goal.

The 2026 guideline brings back specific LDL cholesterol targets, and they're tiered by how much cardiovascular risk you carry [Blumenthal et al., Circulation, 2026]:

• Borderline or intermediate risk (primary prevention): LDL-C below 2.6 mmol/L (100 mg/dL)

• High 10-year risk (≥10%, primary prevention): LDL-C below 1.8 mmol/L (70 mg/dL)

• Established cardiovascular disease (very high risk): LDL-C below 1.4 mmol/L (55 mg/dL)

The guideline also introduces non-HDL cholesterol targets alongside LDL-C targets, which gives a broader picture of your atherogenic risk, particularly useful if your triglycerides are raised.

What this means for you: if you're on a statin or considering one, there's now a clearer number to work towards. It makes monitoring more meaningful and gives you and your doctor a shared goal.

Lp(a): Why More People May Benefit From a Once-in-a-Lifetime Check

This is one of the most significant additions. Lipoprotein(a), written Lp(a) and pronounced "lip-little-a", is a type of cholesterol particle that's largely determined by your genetics. Unlike standard LDL cholesterol, it doesn't change much with diet or statins, and it's not routinely measured on a standard lipid profile.

The 2026 guideline now gives Lp(a) measurement a Class I recommendation (the strongest possible), stating that all adults should have it measured at least once for cardiovascular risk assessment [Blumenthal et al., Circulation, 2026]. Levels above 125 nmol/L (approximately 50 mg/dL) are associated with roughly a 1.4-fold increased risk of cardiovascular disease, and levels above 250 nmol/L (100 mg/dL) are associated with at least double the risk.

Why this matters: a significant proportion of the population (some studies suggest up to one in five people) have an elevated Lp(a), and most of them don't know it. Because it's genetically determined, it won't show up unless you specifically test for it. If your Lp(a) is high, the guideline recommends more intensive management of your other risk factors, particularly LDL cholesterol, to compensate.

That's the US position. UK guidance is more selective about who should be tested, which I come back to in the UK section below.

A New Way of Calculating Your Risk

In the new US guideline, the old risk calculator (the Pooled Cohort Equations, or PCE) is replaced with a newer model called the PREVENT equations. These are designed for adults aged 30 to 79 and can estimate both your 10-year and 30-year cardiovascular risk [Blumenthal et al., Circulation, 2026]. In the UK we currently use QRISK3, which is a different risk calculator used to estimate 10-year cardiovascular risk and guide treatment decisions.

The Case for Treating Cholesterol Earlier

One of the strongest themes in the new guideline is the emphasis on cumulative exposure. Cardiovascular disease doesn't begin the day you have a heart attack. It develops over decades as atherogenic lipoproteins gradually build up in your artery walls. The longer your LDL cholesterol has been elevated, the greater your lifetime risk.

The 2026 guideline now recommends considering statin therapy even in younger adults (aged 30 onwards) who are at low 10-year risk (under 3%) if their LDL cholesterol is between 4.1 and 4.9 mmol/L, or if their 30-year cardiovascular risk is 10% or above [Blumenthal et al., Circulation, 2026]. Previously, treatment in this group would have been unusual unless other risk factors were present.

This is a meaningful shift. It reflects growing evidence that treating earlier, even when short-term risk is low, reduces the total amount of damage done to arteries over a lifetime.

Coronary Artery Calcium Scoring Gets a Major Upgrade

Coronary artery calcium (CAC) scoring, a low-dose CT scan that measures calcified plaque in your coronary arteries, has been used for risk stratification for some time. But the 2026 guideline gives it a much more prominent and specific role.

CAC scores now directly determine LDL cholesterol targets [Blumenthal et al., Circulation, 2026]:

• CAC score of 0: reasonable to defer treatment and recheck in 3–7 years (unless other high-risk features are present)

• CAC 1–99 (below 75th percentile): moderate-intensity statin, targeting LDL-C below 2.6 mmol/L

• CAC 100–299 or ≥75th percentile: treatment to achieve LDL-C below 1.8 mmol/L

• CAC 300–999 (severe): LDL-C below 1.8 mmol/L (70 mg/dL), aiming for at least a 50% reduction

• CAC ≥1000: treated like established heart disease, with an LDL-C target below 1.4 mmol/L

Importantly, the guideline also says that if coronary calcium is spotted incidentally on a CT scan done for another reason, such as a lung screening CT, it should still be acted upon. This includes calcium detected by artificial intelligence algorithms, which is increasingly common.

One UK note before you read too much into this: a CAC scan isn't part of routine NHS cardiovascular risk assessment. I come back to what that means for British patients below.

ApoB: Looking Beyond the Standard Lipid Profile

Apolipoprotein B (ApoB) is a protein found on every atherogenic lipoprotein particle. Because each particle carries exactly one ApoB molecule, measuring it tells you the actual number of harmful particles in your blood, not just the amount of cholesterol they carry.

The 2026 guideline gives ApoB measurement a Class IIa recommendation (meaning "reasonable to do") as a way to refine your risk once LDL-C and non-HDL-C goals have been met [Blumenthal et al., Circulation, 2026]. It's particularly useful if you have elevated triglycerides (above 2.3 mmol/L), diabetes, or a low achieved LDL-C where the standard lipid panel may underestimate residual risk.

Dietary Supplements: Officially Not Recommended

The guideline is direct on this point. Fish oil supplements, garlic, turmeric, cinnamon, red yeast rice, and plant sterols are all given a Class III (No Benefit) recommendation for lowering LDL cholesterol or triglycerides [Blumenthal et al., Circulation, 2026]. The SPORT trial, which directly compared six commonly used supplements against low-dose rosuvastatin and placebo, found that none of the supplements significantly reduced LDL-C compared with placebo, whereas the statin did.

None of this means supplements are useless in general. But for cholesterol specifically, they shouldn't be relied on as an alternative to evidence-based lipid-lowering treatment. One important distinction: prescription omega-3 preparations used for very high triglycerides are a separate treatment, and aren't the same as the over-the-counter fish oil capsules sold for general health. This is worth knowing if you're spending money on supplements in the hope of avoiding a statin.

New Recommendations for Specific Groups

The 2026 guideline adds explicit recommendations for several groups that were either absent or underserved in the 2018 version [Blumenthal et al., Circulation, 2026]:

• Chronic kidney disease (stage 3 or higher): in the US guideline, statin therapy is recommended regardless of LDL-C level in those aged 40–75, with high-intensity treatment for those with established cardiovascular disease. UK guidance also treats chronic kidney disease as high risk, though the exact treatment framework differs.

• People living with HIV: statin therapy is recommended for those aged 40–75 on stable antiretroviral therapy to reduce first cardiovascular events

• Cancer survivors: people with a reasonable life expectancy who otherwise meet the criteria for lipid-lowering therapy shouldn't be excluded from treatment solely because of a cancer history

• Reproductive risk markers: early menopause (before age 45) and adverse pregnancy outcomes such as pre-eclampsia and gestational diabetes are now formally recognised as risk-enhancing factors for cardiovascular disease

Where UK Guidance Stands

If you live in the UK, this is the part that matters most for you. None of this means your GP is behind the times. In the UK we follow NICE guidance as standard, specifically the 2023 guideline on cardiovascular risk and lipid modification, known as NG238 [NICE, 2023], rather than the American guideline. That is completely normal. Guidelines are written and updated at different times in different countries, and NICE looks carefully at the evidence before changing UK practice. The new American guideline may give a sense of one possible direction of travel, but UK practice will depend on NICE's own review of the evidence. Here's how the two approaches compare on the points above.

How your risk is calculated. NICE uses a different calculator called QRISK3, not the PREVENT equations. It estimates your 10-year risk of a heart attack or stroke and is used for adults aged 25 to 84 without existing heart disease. If your risk comes out at 10% or higher, your GP will offer you a statin (atorvastatin 20mg) for primary prevention, after a conversation about the benefits and downsides [NICE, 2023]. That 10% line hasn't changed.

Whether there's a number to aim for. This is where the two countries differ most. For primary prevention, NICE doesn't set an absolute LDL target the way the new American guideline does. Instead, once you're on a statin, the aim is a reduction of more than 40% in your non-HDL cholesterol, usually checked at around three months. Absolute targets only come in for secondary prevention, meaning people who already have cardiovascular disease. For that group, NICE aims for an LDL below 2.0 mmol/L, or a non-HDL below 2.6 mmol/L [NICE, 2023]. That's a more conservative target than the American figure of 1.4 mmol/L for the highest-risk patients.

Lp(a) testing. The American guideline now says every adult should have their Lp(a) checked once. UK guidance hasn't gone that far. NICE doesn't currently recommend testing Lp(a) in everyone. What the UK does have is a HEART UK consensus statement recommending it for specific groups: people with a personal or family history of early heart disease, those with familial hypercholesterolaemia, relatives of people with very high Lp(a), and people with calcific aortic valve disease [HEART UK, Cegla et al., 2019]. So if you fall into one of those groups, there's a clear UK basis for testing.

Coronary calcium scoring. The big expansion of CAC scoring in the US guideline isn't matched here. A calcium scan isn't part of routine NHS cardiovascular risk assessment, and NICE doesn't currently recommend it for that purpose [NICE, 2023].

ApoB. NICE uses non-HDL cholesterol as its standard measure rather than ApoB. ApoB is recognised in the UK as a useful extra test in certain situations, and a 2025 joint statement from HEART UK and the Association for Laboratory Medicine sets out when an enhanced profile including ApoB and Lp(a) is appropriate [HEART UK & ALM, 2025]. But it isn't part of the standard NHS lipid panel.

None of this means the American guideline is wrong. Guidelines move at different speeds, and the US has gone earlier on Lp(a) and calcium scoring than the UK has. But if you're trying to make sense of your own results on the NHS, NICE is the document your GP is working from.

What Should You Do?

If you're already on a statin and your cholesterol is well managed, you probably don't need to change anything right away. But these guidelines do suggest some actions worth considering:

• Consider whether an Lp(a) test is right for you. It only needs to be measured once, and it can reveal a risk that standard tests miss. It's worth thinking about particularly if you have raised cholesterol, a family history of early heart disease, suspected familial hypercholesterolaemia, or you simply want a more detailed cardiovascular risk assessment. Most NHS practices don't test it routinely, but it's available privately.

• Know your targets. If you're on treatment, ask your doctor what LDL-C level you're aiming for. With clear goals in place, monitoring becomes more meaningful.

• Don't rely on supplements for cholesterol management. They shouldn't be used in place of proven lipid-lowering treatment.

• If you're under 50 with raised cholesterol, take it seriously. The emphasis on cumulative exposure means earlier treatment can make a meaningful difference over decades.

If you would like a more detailed picture of your cardiovascular risk, Brooksby Medical offers a private advanced cholesterol profile that includes standard lipid markers alongside ApoB and Lp(a), with a written GP interpretation and the option of a follow-up consultation. This is a paid private service. It is not a replacement for NHS cardiovascular care, but it can provide additional information to support an informed discussion with your own GP.

References

1. Blumenthal RS, Morris PB, et al. 2026 ACC/AHA/Multisociety Guideline on the Management of Dyslipidemia. Circulation. 2026. doi:10.1161/CIR.0000000000001423 (published simultaneously in JACC, doi:10.1016/j.jacc.2025.11.016).

2. National Institute for Health and Care Excellence. Cardiovascular disease: risk assessment and reduction, including lipid modification (NG238). 2023. https://www.nice.org.uk/guidance/ng238

3. Cegla J, Neely RDG, France M, et al. HEART UK consensus statement on Lipoprotein(a): a call to action. Atherosclerosis. 2019;291:62–70. https://pubmed.ncbi.nlm.nih.gov/31704552/

4. Kenkre JS, et al. Standardising lipid testing and reporting in the United Kingdom: a joint statement by HEART UK and the Association for Laboratory Medicine. Annals of Clinical Biochemistry. 2025. https://pubmed.ncbi.nlm.nih.gov/39789723/