New 2026 Lipid Guidelines | Recorded Live at the 2026 ACVS

Presenter: Aman Kakkar, MD, FACC

In this vital session from the 2026 Atlanta Cardiovascular Symposium, founding member of Heart and Vascular Care (HVC), Dr. Kakkar, provides an expert breakdown of the newly released 2026 Lipid Guidelines.

The landscape of cholesterol management has shifted significantly this year.  This presentation is essential for healthcare providers looking to align their practice with the latest standards in cardiovascular prevention and for patients wanting to understand the future of lipid management.

Transcript

SPEAKER_00 0:03

Welcome to put your heart into it, the HBC Podcast centered around educating providers and staff about common clinical scenarios so that we can better treat our patients. Podcasts on this account are meant for educational purposes only and should not be used as a substitute for medical diagnoses or advice. If you have any clinical symptoms or medical questions, please consult a licensed healthcare provider.

SPEAKER_04 0:40

And we have passed out a handout to everyone about the guidelines which came up two weeks ago, and Dr. Pandeya was very kind enough to summarize it and share with us. And thank you, Dr. Pande. And here we go. So why liquid management has changed? Because the the, you know, we have not been doing a good job in assessing the risk. So they came up with a new uh risk uh prevention score for prevent ASTVD. Oh, sorry. There you go. No financial disclosure. Uh so that we're gonna talk about why liquid management has changed, how do we risk uh assessment with the prevent ASTS DVD score, which is the new uh risk calculator, which is replacing the old risk calculator, the primary prevention framework, pharmacological escalation, special population, and some clinical uh cases we'll discuss. Why liquids matter? Because uh obviously ASDVD remains the leading cause of morbid mortality, you know, all this ethrogenic protein exposure and uh stimulative period of time. That is the one thing they're trying to uh get the message home. Consider this like diabetes, like a sugar, you know, starts uh affecting the organs, you know, the day you get diabetes, same thing with the lipids, it starts affecting uh the day you get hypolipidemia. And the primary care is a front line for prevention. And what's new? Uh it is the prevent ASCBD risk equation and earlier starting consideration uh for anybody with a risk of more than 3% uh 10-year risk, return of the LDL and the non-HDL uh targets. If you remember, you know, the 2018 was like 50% reduction, they took it, you know, as as a as a physician, it's hard to what is 50, what is 40 because you know, you because you have to go back what is cholesterol was 20, 10 years ago, whether it's 50% of 10 years ago, whether it's 50% of five years ago, and they took away that LDL of 70, 155 away. Now it's back because it's easy for us to follow rather than just going through the history and trying to figure out what his original LDL was. Uh, universal light away testing, uh, and that Dr. Hoshell is gonna talk about that later, and expanded non-standard options. So this is the central illustration from the guidelines. Uh, and there are four things. Uh, screen earlier, so screen at the age of two if there's a family history of premature uh ASCBD or severe hyperclostolemia or familial hyperclastolemia. Then comes age 9 to 11 to identify FH, that is familial hyperclostolemia and other lipid disorders. So after a 9 to 11, then it jumps to 19 uh screen lipids or for everyone uh at age 19, and then recheck at least every five years using the prevent ASCVD score uh calculator. And uh, I'm gonna go over that calculator in a minute. Uh then aim for a lower LDL score, uh the lower LD, so they're back to the numbers rather than the percentages for ASCVD less than 10% risk. Uh it's 100 million. Uh if ASCVD is more than 10% or FH diabetes uh or CAC score of more than 100, then it is less than 70. And with uh patients with uh clinical ASCBD, which are with multiple other comorities at 55. And so screen earlier, check regularly, and then aim for a lower LDL and treat longer. Uh check lipids uh every 4 to 12 weeks after starting off the initiation of the therapy, and um and the benefits increase with longer therapy. And uh so the the the new score uh calculator is the prevent ASCVD, and uh it is it replaces the Framingham score or the the pooled analysis score, uh and it applies to adults age 30 to 79. It estimates 10 and 30 year ACVD risk, improves calibration, and uh versus the the old pool cohort equation and the risk categories are four less than three percent, three to five percent, five to ten percent, and more than ten percent. And in the pool cohort, it used to be like I think less than five, five to seven point five, seven point five to ten, ten to twenty, and more than twenty. So now they have simplified to less than three, three to five, five to ten, and more than ten percent. And if everybody has their phones, they can scan this QR code. This will bring up to a website called ai.org. And uh I'm gonna get Dr. Bart to demonstrate that.

SPEAKER_01 5:39

I had my labs this week.

SPEAKER_04 5:41

So you're gonna so the first thing in that ASCVD, uh prevent ASCVD calculator is the age. You wanna put in your age? Age 50? You wanna put it in?

unknown 5:52

Sure. Okay.

SPEAKER_04 5:55

And then you put your uh so the other thing is you know, this is also uh sex specific, right? But you know, you can include both males and obviously females. So you put in your uh sex, then about your total cholesterol? Total cholesterol 182. HTL 65. And then you uh any and the other thing they have added is uh actually the blood pressure was there before. So your systolic blood pressure? 120 and EGPR and GFR?

SPEAKER_01 6:27

80.

SPEAKER_04 6:28

So the GFR has been added to this uh risk calculator and what's your score?

SPEAKER_01 6:35

The 10-year score is less than is 1.4%. The 30-year score is 8.8%.

SPEAKER_04 6:43

So that puts you at what category?

SPEAKER_01 6:46

Low.

SPEAKER_04 6:47

Low risk. Okay. So, you know, I have uh if you can use this tool, I have it open on my laptop, and whenever I go to my patient's room now, I just plug in these numbers and uh you uh get the get the score, the 10-year score and a and a 30-year score. And uh it is a very useful tool because if you play with it, it also goes down into you know the risk enhancers, and I'm gonna talk about that. Uh also will uh talk about the primary prevention, uh, you know, what the recommendations are. So, and you can even upload your EHR note into this, and it will uh you know tell our tell what the risk is and what the recommendations are. So it goes over you know all the guidelines we're gonna talk about today. And so the the main premises of the cardiovascular uh risk assessment is CPR. CPR, calculate the risk prediction uh equation, that is the prevent equation, then personalize the risk factor, that is the risk enhancing factors. I'm gonna go over that. And thirdly is reclassify using coronary calcium score. So calculate, personalize the risk enhancing factors, and reclassify using the calcium score. So this is the CPR. First is the calculator score, then it divides into four categories. Uh that is uh the low risk, that's less than three percent, like Dr. Bart. Uh borderline risk, uh I calculated mine, I was a borderline three to five percent. Then the intermediate risk is five to ten, and the high risk is more than ten. Then you personalize based on the uh, you know, further, if the low risk, you don't need to do anything else. Basically, just lifestyle modification. If it is a borderline risk, three to five percent, then you use the uh risk enhancers. And I'm gonna jump the slide real quick and I'm gonna go over the risk enhancers real quick. And the risk enhancers, which you can use in the patients, which majority of our patients will be probably between three and five percent, uh, is if they have a history of premature ASCBD, that is onset of age less than 55 for men, 65 for women, you know that already. Higher uh risk ancestry, they've added South Asian population as a high risk, and also the uh Filipino as a high risk uh risk uh category. High polygenic scores is a DNA, it's a test, you can get the polygenic scores. We haven't started doing it yet. I don't know if anybody else is doing it here. If they have a chronic inflammatory disease like SL lupus or rheumatoid, if their lipo A is above uh 125 nanomoles or 50 milligrams. That the problem with LIPOA nowadays is you know what units, because you get the results from different labs use different units. Somebody used nanomoles, somebody used milligram, so just be careful of that. If your CRP is above two on more than one occasion, so if you have uh at least two times or higher, if your CRP is above, that puts you at a higher risk. Try glycer dry glycerides persistently above 175, non-fasting and fasting above 150, cardiac uh CKM is cardio kidney metabolic syndrome. Uh and if the LDL is persistently high above 160 to 189, uh Epobee has also been added if it's above 120. Uh reproductive risk fact markers came in the for the first time, premature menopause, pre-ecalampsia, gestational hypothesis, gestational hypertension, and preterm. So if you have any of those risk uh enhancers, you actually can well not prescribe, you can prescribe if the patient wants to take it or not, but at least you can tell the patient that because of the risk enhancers, even your risk is 3 to 5 percent, you know, lipid loading may be helpful along with the uh uh uh lifestyle modification. Then the in intermediate risk is 5 to 10. Obviously, discuss the risk uh and the therapy options. And if the patient is reluctant to take uh the calcium, oh sorry, lipid, then you can uh take the help of the calcium score to help guide the therapy. Uh and the high risk of they need to be on uh lipid lowering therapy, uh usually high risk, they will not require calcium score uh because they have already high risk, but sometimes out of the patients still you have to get it done to convince them. This risk enhancement we talked about. And the role of coronary artery calcium, useful when statin as decision is uncertain. If you have a CAC score of zero, it may allow deferral and select patients. CAC score of 100 supports statin initiation for sure. Above 300, they have added this for the first time that should be treated as secondary prevention because it should be assumed that the patient already has significant cornea disease, so it's secondary prevention rather than primary prevention. If you have to take you know one's picture of, take the picture of this slide, because this helps to manage the subclinical atherosclerosis, so uh based on the calcium score. If the score is 1 to 9, oh sorry, 1 to 99, not 9, uh, then you know start moderate intensity statin with an LDL uh target of less than 100. Uh if the score is 100 to 299, then obviously start on LDL lowering therapy, and again the target now is shifted down to less than 70. So if your score is 1 to 100, target is LDL target less than 100. If the score is 100 to 300 or 299, uh the target is now down to less than 70. If it's severe between 300 and again the target is less than 70, and then you add an optional EPOB goal of less than 70. And uh they even recommend going down to 55. I'm have a hard time getting my patients to take a stat and forget about getting the food, you know, uh tightening up the dose, but uh the recommendation is that you can even go up to 55. Uh so the CAC score 399, again uh less than 70, but you can take help of Epob to uh intensify the therapy. Above thousand, you know, the goal now is less than 55, and optional Epobee goal of less than 55. And uh the one more thing they have added is that if you know you order CAT scans all the time for, say, chest, and you get an uh incidental finding of coronary uh calcification. So they uh the recommendation is now that that should be treated as you know, oh sorry, uh that you have calcified uh arteries uh based, and you don't even have to go for a calcium score, but uh to quantify you can. Uh and if you have a mild uh calcification, the goal is uh less than 100, and if it is a moderate to severe calcification on a CT scan, then the goal is uh less than 70. And so this is just uh summarizing the uh the goals, less than 3% lifestyle therapy, 3 to 5, moderate intensity, 5 to 10% risk, moderate to high, more than 10, high high risk, uh intensity statin and addition of non-statins. This is if you want to take a second two pictures only, this is the second picture I would recommend you to take. This is the tribal prevention guideline, and uh it uh so this is these are the patients who have don't have any etherosclerotic heart disease, and adults between uh 30 to 79. Uh there you do the health behavior counseling, calculate the 10-year risk using the ASCVD uh risk calculator, and uh then you divide them into four uh categories and low risk. Low risk, really, you don't need to do anything except uh you know, until unless their LDL is above 160. If their LDL is above 160 in a low risk, uh you uh you can discuss talk uh well if they're ready to take, take a statin and goal is less than 100. If their LDL is less than 160 in a low-risk individual, no need for any uh therapy except for lifestyle uh behavior, lifestyle changes. Borderline risk that is three to five percent. Uh that if they decide if the patient agrees to start a statin, then the goal is less than 100. If the they don't want a statin, then go for the calcium score, and we discuss about the calcium score, how to treat that. The intermediate risk, which is five to ten percent, uh again the recommendation is to start a statin with a goal of less than 100. If they don't want to take a statin, then get a calcium score and base your treatment based on the calcium score. If the calcium score is zero, lifestyle, if calcium score is above uh not zero, even like ten, then you can start lipidlorine therapy. High risk, you know, high intensity statin goal is less than 70. And if the LDL goals are not met, then uh non-uh uh statins can be added, like repatha and rheumatic acid. And uh Mediterranean dash diet, uh limited saturated fats and physical activity as uh Dr. Engels talked about, 150 minutes per week. Uh and uh weight loss improves rigid and LDL. Dietary supplements they are not are not recommending, like you know, all the patients come up uh with uh REDE's rice and uh actually having helping potatoes don't want to take statin, but uh they don't recommend any uh dietary supplements or like red over the counter to reduce uh effects. The foundation is still the statin. If uh the more intensity is turbostatin or a suvastatin, I typically use a resuvin 10 milligrams, high intensity is uh resuvastatin 20 to 40. Um and uh percentage LDL guidelines. Uh there still uh is part of the therapy too, but I'm just going, I usually go by the targets, it's easy for me to uh explain to the patient and myself. Non-statin uh non-statin therapies. They recommend Zeti as the first add-on, PSK9 at high at high and very high risk patients. Uh intolerance, they can take the produic acid, I can never say it, right? And uh LECVO twice yearly dosing for other patients. Uh they came up with hypertric guidelines too. These are managing the adults with hypotychousidemia. Again, they divide it into four categories: uh ASCVD, uh with hypotheticity, hypertritisemia, diabetes, age more than 40, uh, without ASCVD and the severe hypotychusemia. Uh their recommendation is to calculate their ASCVD score. All right, and look for any secondary causes for hypotychicemia. Uh, initial therapy still based on their ASCVD should be statin and lifestyle, uh, and optimize their glycemic control rather than jumping to any uh medication to treat triglycerides. Uh and even after treating their uh you know optimizing their diabetic control and if uh optimizing their LDL and if they are still having uh triglycerides above uh you know 200 or 150, then you can uh treat them with you know the triglyceride medication and triglystite loading medications. So so managing the uh triglycytes above 500. Uh identify and manage the the cause. Uh if the persistent uh and offset uh checking their uh C C V D score, you can divide them into, you know, if the risk is high, which is typically uh you know anytime anything above 5% or definitely above 10%, then uh you can add epoB as also a secondary risk enhancer and add fibric therapy or or omega-3 fatty acids. And if they're triglycer above thousand, then you know obviously uh you're gonna start them on the fibric acid derivatives or the omega-3 fatty acids, and add uh there is a new drug out, Olicerin, olezarsin, uh, for triglycerides above thousand. Uh the next one is uh adults with diabetes without ASCBD. If the diabetics in the young diabetics uh 20 to 39, uh, if their risk is uh less than 3%, which uh uh and you look for uh a risk enhancer in those patients. Uh and the risk and answers for diabetics, they are look uh they recommend obviously you know if you have retinopathy, neuropathy, PAD, uh uh, or uh CKD, or if you have uh you know the albumin in the urine, then consider starting moderate intensity statin. Uh and for the age above again uh 30, if this because the prevent AC ACAVD score is uh can is applicable on the patients if patients age above 30, start uh moderate uh intensity statin if their risk is above 3%. 40 to 75 uh they recommend starting uh L you know lipid lowering therapy uh based on the ASAVD score. And uh so in in a nutshell, uh this is that is a busy slide. So age 40 to 75, at least moderate intensity statin. Uh if they have multiple risk factors, then high intensity statin. LDL goals are less than 100 in the uh uh low to intermediate risk, and in high risk is less than 70, and if the triglycerides are elevated, uh adding ice. Well, sorry. And uh lipoputine A. Uh Dr. Patel's kind of talk on this uh high risk is above 50 and uh intensify LDL. There's a whole uh 20-minute lecture on this. Um coming up, monitoring and follow-up. We talked about earlier recheck 4 to 12 weeks after initiation. Uh and then after then every six to twelve months, uh and take-home is earlier intervention reduces lifetime ACS ASCVD risk. Uh prevent use a prevent ASCVD calculator uh to calculate the risk. Uh LDL target is uh you know 55, 1700, uh and primary care drives the prevention. So we're gonna use uh this case and use the ASCVD calculator, the prevent ASCVD calculator. Forty-five year old male. Still low risk, right? Now you put a calcium score of 40. So based on the risk score, it is low 3%. But now you're gonna personalize and re-classify. You personalize so the calc CPR, calculate the risk, personalize with the risk and answer of uh uh family history. Anytime there's a risk enhancer, it increases your risk. They they haven't quantified the risk, but say, you know, that it goes up another uh level. And with a calcium score of 40, so if you just went by the score, you would have said, you know, patient does not need any any treatment. Right. The score is uh what was this risk? 1.3%? 1.8 1.8%.

SPEAKER_03 23:55

The calcium score basically.

SPEAKER_04 23:58

Right, so 5 over 5%. And what does your calculation say now? What is the treatment? Because this calculator is amazing. This given tells you tells you what to do with the patient. So you want to try to get the LDL go less than a hundred in this patient.

SPEAKER_03 24:20

Right.

SPEAKER_04 24:21

So if the patient agrees, we'll use the item on the statement.

SPEAKER_03 24:29

So it's very helpful for patients and for the provider.

SPEAKER_04 24:34

So yeah, this is the tool I use uh from ai.ai-hard.org. And uh it's a it's uh it's a beautiful uh tool. They also come in with an app. You can download uh the app is not ready yet, but uh use it uh uh when I discuss with the patients and calculate the risk. Alrighty, thank you everyone.

SPEAKER_00 25:01

Thanks for listening. Tune in next time for another cardiology-focused episode.