Revised lipid-lowering therapy guidelines in a nationally representative sample

The 2026 ACC/AHA dyslipidemia guideline introduces PREVENT-based risk assessment, new direct-treatment pathways for comorbid conditions, and long-term risk estimation. The population-level effect of these changes on lipid-lowering therapy recommendations is unknown.

To compare classification of U.S. adults under the 2018 and 2026 dyslipidemia guidelines for treatment recommendations.

Cross-sectional study of the National Health and Nutrition Examination Survey (2013-2023) including adults aged 40 to 75 years with data suitable for guideline classification. Individuals already receiving lipid-lowering therapy were classified separately. Treatment recommendation categories of ``recommended/indicated,'' ``reasonable/favored/selective-consideration,'' and ``not-routinely-recommended'' were constructed for cross-classification of untreated adults between the two guidelines.

The analytic cohort included 6,118 adults representing 118.9 million U.S. adults; 1,984 (weighted, 36.0 million [30.3%]) were already receiving lipid-lowering therapy. Among 4,134 untreated adults (82.9 million), the 2026 guideline classified 1,868 (31.2 million [37.7%]) as recommended/indicated, 1,154 (27.1 million [32.7%]) as reasonable/favored/selectively-considered, and 1,112 (24.6 million [29.7%]) as not-routinely-recommended. Under the 2018 guideline, corresponding counts were 1,289 (21.2 million [25.6%]), 1,107 (21.2 million [25.6%]), and 1,738 (40.5 million [48.9%]). All adults recommended/indicated under the 2018 framework remained so under the 2026 framework, 45.5% of those in the 2018 reasonable stratum moved to the 2026 recommended/indicated stratum, and 39.9% of the previously not-routinely-recommended moved to a higher-intensity category. PREVENT-based pathways accounted for 33.4% of the 2026 recommended/indicated stratum.

Under the 2026 dyslipidemia guideline, an additional 15.9 million (14.1-17.7) untreated Americans aged 40 to 75 years would be newly identified for treatment consideration. The updated guideline substantially reallocates untreated adults toward consideration for treatment.