Doctors should consider treating high cholesterol much earlier and more aggressively than they have in the past, according to a new perspective by Weill Cornell Medicine, NewYork-Presbyterian and Yale School of Medicine investigators. The updated 2026 cholesterol management guidelines from the American College of Cardiology and the American Heart Association encourage doctors to identify risk earlier and intervene before heart attacks and strokes happen. Heart disease remains the leading cause of death in the United States.
The perspective, published May 19 in the Journal of the American College of Cardiology, highlights the role and potential for primary care clinicians to implement the guidelines, while also acknowledging the challenges they may face.
Dr. Madeline Sterling
“Primary care clinicians are really the backbone of patient care, especially when it comes to cardiovascular prevention. Due to our longitudinal relationships with patients we are uniquely positioned to reinforce healthy behaviors related to diet, exercise, sleep and smoking,” said Dr. Madeline R. Sterling, associate professor of medicine at Weill Cornell and an internist at NewYork-Presbyterian/Weill Cornell Medical Center, and lead author of the perspective. Dr. Sterling also served as the Inaugural Chair of the Primary Care Science Committee at the American Heart Association. “Primary care clinicians can screen patients earlier, assess lifetime cardiovascular risk and consider additional risk factors to enhance their management of dyslipidemia—abnormal levels of fats in the bloodstream.”
Dr. Erica S. Spatz, associate professor of cardiology and epidemiology at Yale School of Medicine, also co-authored the perspective.
In the past, treatment decisions often focused on whether someone was likely to have a heart attack or stroke within the next 10 years. However, even younger adults with moderately elevated cholesterol may benefit from earlier intervention if they carry other hidden risks, the authors said.
To better identify those risks, the new guidelines recommend that doctors look beyond standard cholesterol tests and use newer tools including measuring lipoprotein(a), or Lp(a), a genetically inherited cholesterol-related particle linked to heart disease, as well as coronary artery calcium (CAC) scans that can detect silent plaque buildup in the heart’s arteries.
Overall, the guidelines recommend a more aggressive approach to lipid management, including a focus on the cumulative damage cholesterol can cause over a lifetime. This may include starting a statin medication earlier along with lifestyle changes.
But implementing these recommendations may be challenging in practice, Dr. Sterling said
Primary care clinicians often must address competing medical concerns during office visits, which tend to be short. Explaining lifetime cardiovascular risk, advanced cholesterol testing and preventive medications can require detailed conversations that need to occur over time and in concert with cardiologists and other specialists.
Experts also worry that without careful implementation, these advances could widen existing health disparities. Some advanced tests and newer cholesterol-lowering medications may not be covered by insurance or readily available in all communities.
Drs. Sterling and Spatz say successful adoption will likely require better insurance coverage, improved electronic health record tools, patient education efforts, and stronger collaboration between primary care clinicians and specialists, including research and implementation efforts.
The guidelines also promote team-based care, where nurses, pharmacists and specialists help patients manage medications and reach cholesterol targets.
Ultimately, a multi-pronged approach will be necessary for the guideline recommendations to be consistently translated into practice, Dr. Sterling said.
