Counseling Patients on the New Cholesterol Guideline: What Providers Should Know

An updated guideline from the American College of Cardiology (ACC) and the American Heart Association (AHA) calls for aggressive management of dyslipidemia using a suite of tools, including a new risk calculator, individualized LDL cholesterol goals and Lp(a) screening. The aim is to start conversations with patients about high cholesterol early, not just in middle age, according to guideline co-author Leslie Cho, MD, Section Head of Preventive Cardiology and Rehabilitation at Cleveland Clinic.

While patient resistance to statins can be a significant barrier to treatment, a key goal of the new guideline isn’t necessarily to expand the use of statins but rather to highlight and address the risks associated with having high cholesterol over a patient’s entire lifespan, Dr. Cho says.

“The concept of lifetime risk of cardiovascular disease is really important,” she explains. “This is why we are emphasizing checking cholesterol at a young age — not because we want to start everybody on statins early, but because having high cholesterol for a long time makes it more likely that someone will have a heart attack or stroke.”

‘Goals are back,’ Lp(a) testing endorsed

Key takeaways from the guideline for physicians include the new PREVENT calculator, which offers a more nuanced approach to assessing patient risk. That assessment should be used to determine each patient’s individual goal level for LDL cholesterol.

“Goals are back,” Dr. Cho says. “Calculate the risk, and then determine the goal based on that risk.”

The new recommendation that lipoprotein(a), or Lp(a), should be measured at least once in a patient’s lifetime is long overdue, according to Dr. Cho.

“Elevated Lp(a) is a causal risk factor for heart attack, stroke and calcific aortic stenosis, but the percentage of testing in America is around 1%, which is dismal,” she says, noting that the test has been recommended in Europe, Great Britain and Canada for years.

For patients who question why they need the test, which identifies a genetic risk factor they cannot currently control, Dr. Cho points out that it’s an opportunity to address factors that are modifiable, like diet and exercise, to reduce their overall risk.

“It’s also really important to check Lp(a) because if it’s elevated, the chances of your siblings or children having elevated Lp(a) is 50%,” she says. “That resonates with most patients.”

Dealing with statin skepticism

With more therapies than ever, “we live in a great era” for managing high cholesterol, she adds, and yet one of the greatest challenges to better outcomes is patient resistance to testing and treatment.

“The subject of the most fraught discussions in medical offices these days may be vaccines for pediatricians, but for those of us who care for adults, it’s probably statins,” Dr. Cho says.

A significant number of patients express skepticism and mistrust of statins, she notes, and these patients can be hard to convince. She cites one patient in her 50s who did not believe that her coronary artery calcium score of 180 was high because the scan report listed only scores greater than 400 as severe, without breaking down the scores by age. When both her primary care doctor and Dr. Cho tried to explain that her score was actually extremely high for her age, the patient dismissed their warnings.

“She said, ‘This is nothing but a ploy,’” Dr. Cho recalls. “You know what finally convinced her to start a statin? Together we put everything into ChatGPT, and ChatGPT said she should start statins to lower her risk.”

While Dr. Cho doesn’t advocate referring patients to AI, the anecdote points to the difficulty of counseling patients who come into the office with their minds made up, she adds.

Providers can start the conversation by getting on the same page about the aims of treatment. She describes a potential approach: “I might say, ‘We have to have a goal. My goal is for you not to have a heart attack or stroke. Is that the same goal you have? If your goal is just not to be on medicine, our goals are different.’”

Bottom-line takeaways: Listen to the patient, and treat aggressively

While the new guideline, the risk calculator and target levels can be a jumping-off point for those conversations, physicians should approach the issue with patience and sensitivity, Dr. Cho says. She advises addressing a patient’s specific concerns about treatment, like muscle aches or dementia risk.

“Shared decision-making starts with us listening to our patients and really understanding their concern about statins,” she says. “It’s not one and done. If a patient doesn’t want to start statins today, that’s okay, but then bring them back and readdress the issue.”

If patients continue to resist statins, providers can recommend other treatment options. “We’ve now got a lot of tools,” she says.

Overall, she adds, the biggest takeaway for physicians from the new guideline is to treat aggressively. “I really think we continue to see undertreatment of cholesterol,” she says. “Right now, 50% of Americans are not at goal. That’s really sad.”

A welcome update

The new guideline has been welcomed by many providers, according to Ashish Sarraju, MD, a colleague of Dr. Cho’s in Cleveland Clinic’s Section of Preventive Cardiology who wasn’t involved in the guideline’s development.

“These days, preventive cardiology is a fast-moving field, but the 2026 dyslipidemia guideline has done a great job synthesizing important and updated concepts in modern cholesterol management,” Dr. Sarraju says. “These include estimating long-term — that is, 30-year — risk rather than just short-term risk, measuring Lp(a) levels and treating to aggressive lipid goals based on individualized benefit-risk assessment.”

In addition to the ACC and AHA, the updated guideline was developed with the input and endorsement of nine other medical professional societies.