2026 ACC/AHA Cholesterol Guideline Review - Part 4: Who should take cholesterol-lowering medications and who should get a coronary artery calcium (CAC) study?

Introduction

Over the years, who should take a cholesterol-lowering medication has continued to be refined. To sum up prior clinical practice guidelines, patients were generally considered for cholesterol-lowering medication when A) The patient had a history of diabetes, especially adults age 40 and older, stroke, coronary artery disease (includes heart attacks, stents, and cardiac bypass surgery), and peripheral arterial disease (most commonly located in the arteries of the legs) B) The patient had a "bad" LDL cholesterol greater than 190 mg/dL or C) The patient had a 10-year atherosclerotic cardiovascular disease risk that was of intermediate to high risk. Now, it is more nuanced than this, but this is the general picture.

What's different about the new guidelines?

On quick review of the guidelines, there are a few things that are new in terms of recommendations for who gets placed on cholesterol-lowering medication: 1) The algorithm used to calculate 10-year and 30-year risk of heart disease now uses updated, more accurate equations. 2) If someone is of borderline or intermediate risk, or if they have subclinical atherosclerotic disease, then a coronary calcium score can help clarify which patients would benefit from a cholesterol-lowering medication. By the way, the first-line cholesterol-lowering agents are still the statins. Additional options may include ezetimibe (Zetia), PCSK9 monoclonal antibody drugs such as evolocumab (Repatha) and alirocumab (Praluent), and bempedoic acid (Nexletol), depending on the patient’s risk and LDL response. 3) For those at very high risk of heart disease, lowering the LDL lower than 55 mg/dL is recommended rather than the cutoff of those who are just at "high risk." The people who are at "high risk" and not "at very high risk" have an LDL goal typically less than 70 mg/dL. Again, I'm greatly simplifying the guidelines here, but this is the gist. 4) Finally, there appears to be a new recommendation that patients who have chronic kidney disease stage 3 or higher receive statin therapy (stage 3 means that the estimated glomerular filtration rate, or eGFR, on your lab results panel is in the range of 30 to 59 mL/min/1.73 m²) to lower cardiovascular risk.

What is a coronary artery calcium (CAC) score

The coronary artery calcium (CAC) score, or just coronary calcium score, is a way to measure calcium deposition in the arteries of the heart (the coronary arteries). It is a specific type of computerized tomography scan (CT) scan. It is not the same as a routine CT scan. It measures the amount of calcium deposits in the arteries of our heart (the coronary arteries). A higher CAC score generally indicates more coronary atherosclerotic plaque and higher cardiovascular risk. When plaques rupture, our bodies' clotting systems try to repair the damage, just like when we get a clot of blood when we get a cut on our skin surface. When a clot forms in the artery, however, it blocks the blood flow in the artery, causing the heart muscle downstream to die. This is what a heart attack is. Doctors call heart attacks "myocardial infarctions," which means "heart muscle tissue death." This is caused by "myocardial ischemia," which means "lack of blood flow to the heart muscle." When myocardial ischemia occurs for too long as a result of a blood clot forming inside that artery due to arterial plaque rupture, this results in a myocardial infarction, or heart attack.

What do the results of the CAC study mean?

The CAC score is measured in Agatston units (AU). The higher the score, the higher the estimated plaque burden in the coronary arteries. A CAC score of 0 AU is what we want. If you're at borderline or intermediate risk and your CAC score is 0 AU, your doctor may decide that it is reasonable to defer cholesterol-lowering medication in selected situations. A score of 1-9 is minimal, 10-99 is mild, 100-299 is moderate, 300-999 is severe, and anything greater than or equal to 1,000 is considered extensive.

Conclusion

To summarize, those who should be considered for cholesterol-lowering medication still include patients with pre-existing atherosclerotic cardiovascular disease, people with diabetes, especially adults age 40 and older, people with LDL cholesterol over 190 mg/dL, people with chronic kidney disease stage 3, and people at high risk on the 10-year ASCVD risk calculator. These new guidelines also recommend a lower target LDL (<55 mg/dL) for those at very high risk, as well as using the coronary artery calcium (CAC) score to clarify risk in those who are of borderline to intermediate 10-year risk, and in those who have subclinical atherosclerotic cardiovascular disease (atherosclerotic disease that produces no symptoms and has not caused clinically apparent blockages or events).