Interpretation of the 2026 ACC/AHA Multisociety Guideline on the Management of Dyslipidemia_CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Authors：

SU Canfeng ¹ ,  HUANG Zhihang ¹ ,  WU Nianwei ²

1. Department of Cardiology, Xiang’an Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, Fujian 361100, P. R. China;
2. Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu 610041, P. R. China;

Corresponding?author：

HUANG Zhihang, Email: zhihang823109@163.com; WU Nianwei, Email: 249437903@qq.com

Keywords：

dyslipidemia; low-density lipoprotein cholesterol; atherosclerotic cardiovascular disease; guideline interpretation; lipid-lowering therapy

DOI：

10.7507/1007-9424.202605110

Video：

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The 2026 American College of Cardiology/American Heart Association multisociety guideline on the management of dyslipidemia provides a comprehensive update to the 2018 cholesterol guideline. With the prevention of ASCVD (atherosclerotic cardiovascular disease) as its central goal, the new guideline emphasizes earlier identification, earlier intervention, and long-term management of dyslipidemia to reduce lifetime exposure to atherogenic lipoproteins. The PREVENT-ASCVD equations are recommended to replace the previous Pooled Cohort Equations for 10-year and 30-year cardiovascular risk assessment. Low-density lipoprotein cholesterol and non-high-density lipoprotein cholesterol treatment goals are re-emphasized in clinical decision-making, and apolipoprotein B and lipoprotein(a) are assigned more important roles in risk refinement. In terms of treatment, statins remain the foundation of lipid-lowering therapy, while the roles of ezetimibe, proproteinconvertase subtilisin/kexin type 9 monoclonal antibodies, bempedoic acid, inclisiran, and apolipoprotein C3 inhibitors are further clarified. This article interprets the background, key updates, primary and secondary prevention strategies, use of special lipid biomarkers, management of hypertriglyceridemia, and positioning of novel lipid-lowering therapies in the 2026 guideline, and discusses their implications for dyslipidemia management in China.

Citation： SU Canfeng, HUANG Zhihang, WU Nianwei. Interpretation of the 2026 ACC/AHA Multisociety Guideline on the Management of Dyslipidemia. CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY, 2026, 33(9): 1185-1196. doi: 10.7507/1007-9424.202605110 Copy

1.	Yun SY, Rim JH, Kang H, et al. Associations of LDL cholesterol, non-HDL cholesterol, and apolipoprotein B with cardiovascular disease occurrence in adults: Korean Genome and Epidemiology Study [J]. Ann Lab Med, 2023, 43(3): 237-243.
2.	Helgadottir A, Thorleifsson G, Snaebjarnarson A, et al. Cholesterol not particle concentration mediates the atherogenic risk conferred by apolipoprotein B particles: a Mendelian randomization analysis [J]. Eur J Prev Cardiol, 2022, 29(18): 2374-2385.
3.	Silverman MG, Ference BA, Im K, et al. Association between lowering LDL-C and cardiovascular risk reduction among different therapeutic interventions: a systematic review and meta-analysis [J]. JAMA, 2016, 316(12): 1289-1297.
4.	Sabatine MS, Giugliano RP, Keech AC, et al. Evolocumab and clinical outcomes in patients with cardiovascular disease [J]. N Engl J Med, 2017, 376(18): 1713-1722.
5.	Nissen SE, Lincoff AM, Brennan D, et al. Bempedoic acid and cardiovascular outcomes in statin-intolerant patients [J]. N Engl J Med, 2023, 388(15): 1353-1364.
6.	Willeit P, Ridker PM, Nestel PJ, et al. Baseline and on-statin treatment lipoprotein(a) levels for prediction of cardiovascular events: individual patient-data meta-analysis of statin outcome trials [J]. Lancet, 2018, 392(10155): 1311-1320.
7.	Patel AP, Wang M, Pirruccello JP, et al. Lp(a) (lipoprotein[a]) concentrations and incident atherosclerotic cardiovascular disease: new insights from a large national biobank [J]. Arterioscler Thromb Vasc Biol, 2021, 41(1): 465-474.
8.	Johannesen CDL, Mortensen MB, Langsted A, et al. Apolipoprotein B and non-HDL cholesterol better reflect residual risk than LDL cholesterol in statin-treated patients [J]. J Am Coll Cardiol, 2021, 77(11): 1439-1450.
9.	Marston NA, Giugliano RP, Melloni GEM, et al. Association of apolipoprotein B-containing lipoproteins and risk of myocardial infarction in individuals with and without atherosclerosis: distinguishing between particle concentration, type, and content [J]. JAMA Cardiol, 2022, 7(3): 250-256.
10.	Nasir K, Bittencourt MS, Blaha MJ, et al. Implications of coronary artery calcium testing among statin candidates according to American College of Cardiology/American Heart Association Cholesterol Management Guidelines: MESA (Multi-Ethnic Study of Atherosclerosis) [J]. J Am Coll Cardiol, 2015, 66(15): 1657-1668.
11.	Mahabadi AA, M?hlenkamp S, Lehmann N, et al. CAC score improves coronary and CV risk assessment above statin indication by ESC and AHA/ACC primary prevention guidelines [J]. JACC Cardiovasc Imaging, 2017, 10(2): 143-153.
12.	Lindholt JS, S?gaard R, Rasmussen LM, et al. Five-year outcomes of the Danish Cardiovascular Screening (DANCAVAS) Trial [J]. N Engl J Med, 2022, 387(15): 1385-1394.
13.	Kirk EP, Klein S. Pathogenesis and pathophysiology of the cardiometabolic syndrome [J]. J Clin Hypertens (Greenwich), 2009, 11(12): 761-765.
14.	Blumenthal RS, Morris PB, Gaudino M, et al. 2026 ACC/AHA/AACVPR/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of dyslipidemia: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines [J]. J Am Coll Cardiol, 2026, 87(19): 2624-2757.
15.	Andrus B, Lacaille D. 2013 ACC/AHA guideline on the assessment of cardiovascular risk [J/OL]. J Am Coll Cardiol, 2014, 63(25 Pt A): 2886. doi: 10.1016/j.jacc.2014.02.606.
16.	Khan SS, Matsushita K, Sang Y, et al. Development and validation of the American Heart Association’s PREVENT equations [J]. Circulation, 2024, 149(6): 430-449.
17.	Cholesterol Treatment Trialists’ (CTT) Collaborators; Mihaylova B, Emberson J, et al. The effects of lowering LDL cholesterol with statin therapy in people at low risk of vascular disease: meta-analysis of individual data from 27 randomised trials [J]. Lancet, 2012, 380(9841): 581-590.
18.	Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines [J]. J Am Coll Cardiol, 2014, 63(25 Pt B): 2889-2934.
19.	Ahmed ST, Akeroyd JM, Mahtta D, et al. Shared decisions: a qualitative study on clinician and patient perspectives on statin therapy and statin-associated side effects [J/OL]. J Am Heart Assoc, 2020, 9(22): e017915. doi: 10.1161/JAHA.120.017915.
20.	Pencina MJ, D’Agostino RB, Zdrojewski T, et al. Apolipoprotein B improves risk assessment of future coronary heart disease in the Framingham Heart Study beyond LDL-C and non-HDL-C [J]. Eur J Prev Cardiol, 2015, 22(10): 1321-1327.
21.	Emerging Risk Factors Collaboration; Erqou S, Kaptoge S, et al. Lipoprotein(a) concentration and the risk of coronary heart disease, stroke, and nonvascular mortality [J]. JAMA, 2009, 302(4): 412-423.
22.	Trinder M, Paruchuri K, Haidermota S, et al. Repeat measures of lipoprotein(a) molar concentration and cardiovascular risk [J]. J Am Coll Cardiol, 2022, 79(7): 617-628.
23.	Ray KK, Vallejo-Vaz AJ, Ginsberg HN, et al. Lipoprotein(a) reductions from PCSK9 inhibition and major adverse cardiovascular events: pooled analysis of alirocumab phase 3 trials [J]. Atherosclerosis, 2019, 288: 194-202.
24.	Stürzebecher PE, Schorr JJ, Klebs SHG, et al. Trends and consequences of lipoprotein(a) testing: cross-sectional and longitudinal health insurance claims database analyses [J]. Atherosclerosis, 2023, 367: 24-33.
25.	O’Donoghue ML, Fazio S, Giugliano RP, et al. Lipoprotein(a), PCSK9 inhibition, and cardiovascular risk [J]. Circulation, 2019, 139(12): 1483-1492.
26.	Bittner VA, Szarek M, Aylward PE, et al. Effect of alirocumab on lipoprotein(a) and cardiovascular risk after acute coronary syndrome [J]. J Am Coll Cardiol, 2020, 75(2): 133-144.
27.	Koch CA, Kjeldsen EW, Frikke-Schmidt R. Vegetarian or vegan diets and blood lipids: a meta-analysis of randomized trials [J]. Eur Heart J, 2023, 44(28): 2609-2622.
28.	Estruch R, Martínez-González MA, Corella D, et al. Effects of a Mediterranean-style diet on cardiovascular risk factors: a randomized trial [J]. Ann Intern Med, 2006, 145(1): 1-11.
29.	Smart NA, Downes D, van der Touw T, et al. The effect of exercise training on blood lipids: a systematic review and meta-analysis [J]. Sports Med, 2025, 55(1): 67-78.
30.	Hasan B, Nayfeh T, Alzuabi M, et al. Weight loss and serum lipids in overweight and obese adults: a systematic review and meta-analysis [J/OL]. J Clin Endocrinol Metab, 2020, 105(12): dgaa673. doi: 10.1210/clinem/dgaa673.
31.	Domanski MJ, Tian X, Wu CO, et al. Time course of LDL cholesterol exposure and cardiovascular disease event risk [J]. J Am Coll Cardiol, 2020, 76(13): 1507-1516.
32.	Ridker PM, Danielson E, Fonseca FA, et al. Rosuvastatin to prevent vascular events in men and women with elevated C-reactive protein [J]. N Engl J Med, 2008, 359(21): 2195-2207.
33.	Baigent C, Landray MJ, Reith C, et al. The effects of lowering LDL cholesterol with simvastatin plus ezetimibe in patients with chronic kidney disease (Study of Heart and Renal Protection): a randomised placebo-controlled trial [J]. Lancet, 2011, 377(9784): 2181-2192.
34.	Cholesterol Treatment Trialists’ (CTT) Collaboration; Baigent C, Blackwell L, et al. Efficacy and safety of more intensive lowering of LDL cholesterol: a meta-analysis of data from 170 000 participants in 26 randomised trials [J]. Lancet, 2010, 376(9753): 1670-1681.
35.	Cholesterol Treatment Trialists’ (CTT) Collaboration; Fulcher J, O’Connell R, et al. Efficacy and safety of LDL-lowering therapy among men and women: meta-analysis of individual data from 174 000 participants in 27 randomised trials [J]. Lancet, 2015, 385(9976): 1397-1405.
36.	Cannon CP, Blazing MA, Giugliano RP, et al. Ezetimibe added to statin therapy after acute coronary syndromes [J]. N Engl J Med, 2015, 372(25): 2387-2397.
37.	Schwartz GG, Steg PG, Szarek M, et al. Alirocumab and cardiovascular outcomes after acute coronary syndrome [J]. N Engl J Med, 2018, 379(22): 2097-2107.
38.	O’Donoghue ML, Giugliano RP, Wiviott SD, et al. Long-term evolocumab in patients with established atherosclerotic cardiovascular disease [J]. Circulation, 2022, 146(15): 1109-1119.
39.	Ray KK, Wright RS, Kallend D, et al. Two phase 3 trials of inclisiran in patients with elevated LDL cholesterol [J]. N Engl J Med, 2020, 382(16): 1507-1519.
40.	Stroes ESG, Alexander VJ, Karwatowska-Prokopczuk E, et al. Olezarsen, acute pancreatitis, and familial chylomicronemia syndrome [J]. N Engl J Med, 2024, 390(19): 1781-1792.
41.	Watts GF, Rosenson RS, Hegele RA, et al. Plozasiran for managing persistent chylomicronemia and pancreatitis risk [J]. N Engl J Med, 2025, 392(2): 127-137.
42.	中國血脂管理指南修訂聯合專家委員會. 中國血脂管理指南 (2023年) [J]. 中華心血管病雜志, 2023, 51(3): 221-255.

1. Yun SY, Rim JH, Kang H, et al. Associations of LDL cholesterol, non-HDL cholesterol, and apolipoprotein B with cardiovascular disease occurrence in adults: Korean Genome and Epidemiology Study [J]. Ann Lab Med, 2023, 43(3): 237-243.
2. Helgadottir A, Thorleifsson G, Snaebjarnarson A, et al. Cholesterol not particle concentration mediates the atherogenic risk conferred by apolipoprotein B particles: a Mendelian randomization analysis [J]. Eur J Prev Cardiol, 2022, 29(18): 2374-2385.
3. Silverman MG, Ference BA, Im K, et al. Association between lowering LDL-C and cardiovascular risk reduction among different therapeutic interventions: a systematic review and meta-analysis [J]. JAMA, 2016, 316(12): 1289-1297.
4. Sabatine MS, Giugliano RP, Keech AC, et al. Evolocumab and clinical outcomes in patients with cardiovascular disease [J]. N Engl J Med, 2017, 376(18): 1713-1722.
5. Nissen SE, Lincoff AM, Brennan D, et al. Bempedoic acid and cardiovascular outcomes in statin-intolerant patients [J]. N Engl J Med, 2023, 388(15): 1353-1364.
6. Willeit P, Ridker PM, Nestel PJ, et al. Baseline and on-statin treatment lipoprotein(a) levels for prediction of cardiovascular events: individual patient-data meta-analysis of statin outcome trials [J]. Lancet, 2018, 392(10155): 1311-1320.
7. Patel AP, Wang M, Pirruccello JP, et al. Lp(a) (lipoprotein[a]) concentrations and incident atherosclerotic cardiovascular disease: new insights from a large national biobank [J]. Arterioscler Thromb Vasc Biol, 2021, 41(1): 465-474.
8. Johannesen CDL, Mortensen MB, Langsted A, et al. Apolipoprotein B and non-HDL cholesterol better reflect residual risk than LDL cholesterol in statin-treated patients [J]. J Am Coll Cardiol, 2021, 77(11): 1439-1450.
9. Marston NA, Giugliano RP, Melloni GEM, et al. Association of apolipoprotein B-containing lipoproteins and risk of myocardial infarction in individuals with and without atherosclerosis: distinguishing between particle concentration, type, and content [J]. JAMA Cardiol, 2022, 7(3): 250-256.
10. Nasir K, Bittencourt MS, Blaha MJ, et al. Implications of coronary artery calcium testing among statin candidates according to American College of Cardiology/American Heart Association Cholesterol Management Guidelines: MESA (Multi-Ethnic Study of Atherosclerosis) [J]. J Am Coll Cardiol, 2015, 66(15): 1657-1668.
11. Mahabadi AA, M?hlenkamp S, Lehmann N, et al. CAC score improves coronary and CV risk assessment above statin indication by ESC and AHA/ACC primary prevention guidelines [J]. JACC Cardiovasc Imaging, 2017, 10(2): 143-153.
12. Lindholt JS, S?gaard R, Rasmussen LM, et al. Five-year outcomes of the Danish Cardiovascular Screening (DANCAVAS) Trial [J]. N Engl J Med, 2022, 387(15): 1385-1394.
13. Kirk EP, Klein S. Pathogenesis and pathophysiology of the cardiometabolic syndrome [J]. J Clin Hypertens (Greenwich), 2009, 11(12): 761-765.
14. Blumenthal RS, Morris PB, Gaudino M, et al. 2026 ACC/AHA/AACVPR/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of dyslipidemia: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines [J]. J Am Coll Cardiol, 2026, 87(19): 2624-2757.
15. Andrus B, Lacaille D. 2013 ACC/AHA guideline on the assessment of cardiovascular risk [J/OL]. J Am Coll Cardiol, 2014, 63(25 Pt A): 2886. doi: 10.1016/j.jacc.2014.02.606.
16. Khan SS, Matsushita K, Sang Y, et al. Development and validation of the American Heart Association’s PREVENT equations [J]. Circulation, 2024, 149(6): 430-449.
17. Cholesterol Treatment Trialists’ (CTT) Collaborators; Mihaylova B, Emberson J, et al. The effects of lowering LDL cholesterol with statin therapy in people at low risk of vascular disease: meta-analysis of individual data from 27 randomised trials [J]. Lancet, 2012, 380(9841): 581-590.
18. Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines [J]. J Am Coll Cardiol, 2014, 63(25 Pt B): 2889-2934.
19. Ahmed ST, Akeroyd JM, Mahtta D, et al. Shared decisions: a qualitative study on clinician and patient perspectives on statin therapy and statin-associated side effects [J/OL]. J Am Heart Assoc, 2020, 9(22): e017915. doi: 10.1161/JAHA.120.017915.
20. Pencina MJ, D’Agostino RB, Zdrojewski T, et al. Apolipoprotein B improves risk assessment of future coronary heart disease in the Framingham Heart Study beyond LDL-C and non-HDL-C [J]. Eur J Prev Cardiol, 2015, 22(10): 1321-1327.
21. Emerging Risk Factors Collaboration; Erqou S, Kaptoge S, et al. Lipoprotein(a) concentration and the risk of coronary heart disease, stroke, and nonvascular mortality [J]. JAMA, 2009, 302(4): 412-423.
22. Trinder M, Paruchuri K, Haidermota S, et al. Repeat measures of lipoprotein(a) molar concentration and cardiovascular risk [J]. J Am Coll Cardiol, 2022, 79(7): 617-628.
23. Ray KK, Vallejo-Vaz AJ, Ginsberg HN, et al. Lipoprotein(a) reductions from PCSK9 inhibition and major adverse cardiovascular events: pooled analysis of alirocumab phase 3 trials [J]. Atherosclerosis, 2019, 288: 194-202.
24. Stürzebecher PE, Schorr JJ, Klebs SHG, et al. Trends and consequences of lipoprotein(a) testing: cross-sectional and longitudinal health insurance claims database analyses [J]. Atherosclerosis, 2023, 367: 24-33.
25. O’Donoghue ML, Fazio S, Giugliano RP, et al. Lipoprotein(a), PCSK9 inhibition, and cardiovascular risk [J]. Circulation, 2019, 139(12): 1483-1492.
26. Bittner VA, Szarek M, Aylward PE, et al. Effect of alirocumab on lipoprotein(a) and cardiovascular risk after acute coronary syndrome [J]. J Am Coll Cardiol, 2020, 75(2): 133-144.
27. Koch CA, Kjeldsen EW, Frikke-Schmidt R. Vegetarian or vegan diets and blood lipids: a meta-analysis of randomized trials [J]. Eur Heart J, 2023, 44(28): 2609-2622.
28. Estruch R, Martínez-González MA, Corella D, et al. Effects of a Mediterranean-style diet on cardiovascular risk factors: a randomized trial [J]. Ann Intern Med, 2006, 145(1): 1-11.
29. Smart NA, Downes D, van der Touw T, et al. The effect of exercise training on blood lipids: a systematic review and meta-analysis [J]. Sports Med, 2025, 55(1): 67-78.
30. Hasan B, Nayfeh T, Alzuabi M, et al. Weight loss and serum lipids in overweight and obese adults: a systematic review and meta-analysis [J/OL]. J Clin Endocrinol Metab, 2020, 105(12): dgaa673. doi: 10.1210/clinem/dgaa673.
31. Domanski MJ, Tian X, Wu CO, et al. Time course of LDL cholesterol exposure and cardiovascular disease event risk [J]. J Am Coll Cardiol, 2020, 76(13): 1507-1516.
32. Ridker PM, Danielson E, Fonseca FA, et al. Rosuvastatin to prevent vascular events in men and women with elevated C-reactive protein [J]. N Engl J Med, 2008, 359(21): 2195-2207.
33. Baigent C, Landray MJ, Reith C, et al. The effects of lowering LDL cholesterol with simvastatin plus ezetimibe in patients with chronic kidney disease (Study of Heart and Renal Protection): a randomised placebo-controlled trial [J]. Lancet, 2011, 377(9784): 2181-2192.
34. Cholesterol Treatment Trialists’ (CTT) Collaboration; Baigent C, Blackwell L, et al. Efficacy and safety of more intensive lowering of LDL cholesterol: a meta-analysis of data from 170 000 participants in 26 randomised trials [J]. Lancet, 2010, 376(9753): 1670-1681.
35. Cholesterol Treatment Trialists’ (CTT) Collaboration; Fulcher J, O’Connell R, et al. Efficacy and safety of LDL-lowering therapy among men and women: meta-analysis of individual data from 174 000 participants in 27 randomised trials [J]. Lancet, 2015, 385(9976): 1397-1405.
36. Cannon CP, Blazing MA, Giugliano RP, et al. Ezetimibe added to statin therapy after acute coronary syndromes [J]. N Engl J Med, 2015, 372(25): 2387-2397.
37. Schwartz GG, Steg PG, Szarek M, et al. Alirocumab and cardiovascular outcomes after acute coronary syndrome [J]. N Engl J Med, 2018, 379(22): 2097-2107.
38. O’Donoghue ML, Giugliano RP, Wiviott SD, et al. Long-term evolocumab in patients with established atherosclerotic cardiovascular disease [J]. Circulation, 2022, 146(15): 1109-1119.
39. Ray KK, Wright RS, Kallend D, et al. Two phase 3 trials of inclisiran in patients with elevated LDL cholesterol [J]. N Engl J Med, 2020, 382(16): 1507-1519.
40. Stroes ESG, Alexander VJ, Karwatowska-Prokopczuk E, et al. Olezarsen, acute pancreatitis, and familial chylomicronemia syndrome [J]. N Engl J Med, 2024, 390(19): 1781-1792.
41. Watts GF, Rosenson RS, Hegele RA, et al. Plozasiran for managing persistent chylomicronemia and pancreatitis risk [J]. N Engl J Med, 2025, 392(2): 127-137.
42. 中國血脂管理指南修訂聯合專家委員會. 中國血脂管理指南 (2023年) [J]. 中華心血管病雜志, 2023, 51(3): 221-255.

CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Interpretation of the 2026 ACC/AHA Multisociety Guideline on the Management of Dyslipidemia

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