Dyslipidemia management is back in the spotlight, driven in part by a recent focused update from the European Society of Cardiology (ESC)/European Atherosclerosis Society (EAS) and forthcoming guidelines from the American Heart Association (AHA) and American College of Cardiology (ACC). 

The specifics in the AHA/ACC update are under wraps until their release sometime in the first quarter of 2026. In the meantime, advice from Europe, combined with recently published evidence and expert perspectives, offers clues to what might soon be included in US guidance.

The last AHA/ACC dyslipidemia update was in 2019. “There’s been a lot of really important science that has been published since the last iteration of the guidelines, in the US at least,” Nishant Shah, MD, a cardiologist at the Duke Heart Center and the Duke Clinical Research Institute in Durham, North Carolina, told Medscape Medical News. 

“A lot of this late-breaking science has been on novel therapeutics and on justifying lower LDL-C [low-density lipoprotein cholesterol] goals in some of our most high-risk populations,” added Shah, who is also an associate professor of cardiology at Duke University. 

New Risk Assessments

A risk calculator called SCORE2, an emphasis on coronary artery calcium, and lower LDL cholesterol targets for some higher-risk populations were among the new recommendations in the 2025 Focused Update of the 2019 European guidelines for the management of dyslipidemias, which was released in August 2025.

One major difference likely to remain between European and American guidelines is the use of the long-term calculators for total cardiovascular risk. The European SCORE2 and SCORE2-OP calculators replaced earlier algorithms last year.

The 2019 American guidelines initially recommended the ACC/AHA Cardiovascular Risk Calculator, which was replaced with the AHA PREVENT calculator in 2023. PREVENT incorporates younger populations, people who are obese, and those with kidney dysfunction or other cardiometabolic risk factors.

Elevated Risk in Younger People

Cardiologists are seeing more younger patients with established cardiovascular disease, which raises the question of whether to introduce lipid-lowering therapies earlier.

Even if someone falls within normal limits on their lipid panel, physicians should consider “risk enhancers,” Shah said. Examples include elevated lipoprotein(a) [Lp(a)] levels, presence of coronary artery calcium, a history of preeclampsia or premature menopause, an early family history of inflammatory disease, chronic kidney disease, or South Asian ancestry. 

Smaller reductions in lipid levels at younger ages appear to be more beneficial than larger reductions at older ages or once cardiovascular disease has already developed, Konstantinos Koskinas, MD, co-chair of the updated European guidelines, told Medscape Medical News. 

“There is robust and growing evidence from epidemiologic, genetic, and imaging studies showing that in persons with elevated lipid levels, early treatment is indeed associated with a lower long-term risk of developing cardiovascular disease,” Koskinas said. 

However, this recommendation does not apply when lipid levels are normal, and there is no evidence of heightened cardiovascular risk, added Koskinas, a cardiologist at Bern University Hospital in Bern, Switzerland. Instead, the ESC/ESA guidelines encourage a healthy lifestyle from a young age, starting during childhood and adolescence. 

Hospitalization: A Teaching Moment

Starting lipid-lowering therapy during initial hospitalization for a myocardial infarction or other acute coronary syndrome event is another new recommendation from the European experts. 

Shah supported this approach. “There is very clear data that the earlier you lower LDL after an atherosclerotic cardiovascular disease event and the longer that low LDL is sustained, the better the patients do. There are studies that also have shown a mortality benefit with that strategy.” 

An initial hospitalization can also be a life-changing event. 

“Life hits [patients] really differently then, so that at that point, they are super engaged and super willing to learn. This is a window of opportunity where you can really help them understand their LDL goal so that they can take an active role in their health care and advocate for themselves,” Shah said. 

Beyond LDL Cholesterol

Guidelines have long focused on LDL cholesterol levels as a surrogate marker for atherosclerosis, Robert Rosenson, MD, professor of cardiovascular medicine at the Icahn School of Medicine at Mount Sinai and system director of metabolism and lipids for the Mount Sinai Health System in New York City, told Medscape Medical News. 

“But we know that LDL cholesterol may underrepresent cardiovascular risk, particularly in people that have characteristics of metabolic syndrome,” he said. Obesity, high triglycerides, low levels of high-density lipoprotein (HDL) cholesterol, prediabetes, and diabetes are examples.

LDL particles can be a more accurate predictor of cardiovascular risk in this population, Rosenson said. “It may be that treatments that focus on LDL cholesterol alone in that population are not treating those patients as aggressively as they need to be based on the circulating number of LDL particles.” It’s unclear whether new US guidelines will recommend testing beyond LDL cholesterol.

Bempedoic Acid 

The ESC/ESA guidelines suggest bempedoic acid for lowering LDL cholesterol levels in some patients. It has been tested mainly in patients who cannot tolerate statins, but also as an add-on therapy to statin treatment. 

The CLEAR trial, for example, demonstrated that bempedoic acid reduced LDL cholesterol by 21%-30% and reduced the risk for major adverse cardiovascular events by 13%-15% in high-risk, statin-intolerant patients. The agent also reduced heart attacks by 23% and coronary revascularizations by 19% over 4 years. 

Rosenson raised some concerns. “A lot of insurance plans don’t cover it. It’s very expensive. For most of my patients with Medicare, it’s unaffordable.”

In addition, bempedoic acid treatment carries an increased risk for elevated uric acid and gout, so additional monitoring and testing are required.

Renewed Interest in Lp(a)

The ESC/EAS Focused Update recommends checking Lp(a) levels at least once in a patient’s lifetime as part of overall risk assessment.

“As much as I agree with that recommendation, if we look across the world, we’re just not seeing that being implemented,” Shah said. For example, he led a 2024 study that found fewer than 1% of nearly 600,000 US patients were tested for Lp(a).

Screening may be low because physicians are not sure what to do with the results or because there are no therapeutics yet approved to treat abnormally elevated levels. However, Shah argued, “It certainly can serve as a marker of risk that may dictate if you start someone on cholesterol-lowering therapy or not.”

Rosenson recommended testing for Lp(a) at least twice to correct for any biologic variability or one-time abnormal result. He also acknowledged that statin therapy can raise Lp(a) levels, but that concern is offset by the degree of risk reduction associated with statins.

Nutritional Supplements

It remains to be seen if the AHA/ACC 2026 guidelines will recommend any nutritional supplements. But the ESC/EAS experts did not, citing a lack of robust evidence supporting their benefit. 

“We just don’t know enough about them,” Shah said. “I tend to stay away from supplements and focus more on evidence-based therapies.”

Even so, they remain popular. “Nutritional supplements are used extensively by patients who wish to lower their elevated lipid levels,” Koskinas said. “Some of these supplements may indeed have an effect on lipid levels, although this effect is small at best.”

“Moreover, there have been safety concerns with some supplements, as discussed in detail in our guideline,” Koskinas added.

Regardless of what the AHA/ACC guidelines include in their update, a practical consideration across consensus guidelines remains — their application, Shah said. “We can get these new guidelines, but if we don’t implement the findings or the guidance, it’s not going to make a difference. That’s how we move the clinical needle forward.”

Medscape Medical News will highlight updates in the AHA/ACC 2026 guidelines on dyslipidemia management once they become publicly available. 

Shah disclosed being a consultant for Novartis, Amgen, Amarin, Esperion, Amarin, NewAmsterdam Pharma, Arrow Pharma, Regeneron, and Merck. He also reported receiving research support from the National Institutes of Health, Amgen, Novartis, Janssen, Eli Lilly, NewAmsterdam Pharma, AstraZeneca, and Regeneron. Koskinas disclosed receiving personal research support from Sanofi-Aventis and Merck Sharp & Dohme and support to his institution from Daiichi Sankyo and Sanofi-Aventis. Rosenson had no relevant financial disclosures. 

Damian McNamara is a freelance contributor to Medscape Medical News. He worked full-time for Medscape and WebMD from 2018 to 2024. Damian has a BA in chemistry and an MA in science, health, and environmental reporting/journalism. He works out of a home office in Miami, with a 100-pound chocolate lab known to snore under his desk during work hours.