- Three studies used nationally representative survey data to project how the new dyslipidemia guideline would affect population health.
- A large percentage of U.S. adults age 30 or older were new candidates for guideline-directed lipid-lowering therapy based on updated guideline criteria, one study showed.
- Another study found that in those age 40-79, the proportion of people who may be recommended lipid-lowering therapy was 49.6% with the 2026 guideline versus 49.4% before the guideline.
The new American cholesterol guideline would not make more Americans statin users per se, but instead shift the profile of people who should initiate lipid-lowering therapy to those younger and lower risk, research indicated.
Based on National Health and Nutrition Examination Survey (NHANES) cycles 2017-2023, an estimated 87.5 million (56.6%) nonpregnant U.S. adults age 30-79 years were statin eligible based on the 2026 guideline, including 21.5 million (13.9%) who were newly statin eligible. Newly statin-eligible populations were largely younger and lower risk than populations previously recommended statin therapy from the older guideline (mean estimated 10-year atherosclerotic cardiovascular disease risk 3.1% vs 6.1%).
“The 2026 dyslipidemia guideline substantially expands the U.S. population recommended for primary prevention statin therapy, predominantly in lower-risk individuals,” reported a trio led by Timothy Anderson, MD, MAS, of the University of Pittsburgh, in JAMA.
“The shift to a longer view of cardiovascular disease risk is a sea change for doctors in counseling patients,” Anderson said in a press release. “Before the new guidelines, people who were flagged with high cholesterol in their 30s and 40s tended to be recommended to focus on diet and exercise and were not recommended medication — unless the patient already had heart disease or other factors that made them particularly high-risk, like diabetes.”
Two accompanying studies similarly backed the finding that a large percentage of U.S. adults age 30 or older should be candidates for guideline-directed lipid-lowering therapy based on new guideline criteria.
This year’s updated lipid guideline is notable for introducing the PREVENT equations as a guide for lipid-lowering therapy in primary prevention. The switch to PREVENT, known to yield risk estimates that are substantially lower than those from the older pooled cohort equations, has it that lipid-lowering therapy can now be considered with a 10-year PREVENT-ASCVD risk estimate of 3% to <5% (borderline) and should be considered for those at 5% to <10% (intermediate) 10-year risk.
One group projected that the new guideline reclassifies over one in five adults based on the PREVENT equations: two-thirds of those reassigned to lower-risk categories and one-third reassigned to higher-risk categories. Men (24.2%), Black individuals (29.6%), and current smokers (27.7%) were most frequently reassigned downward in risk, whereas women (11.1%) and individuals with diabetes (20.4%) were more often reassigned upward.
This second NHANES analysis, also in JAMA, found that the overall pool of older statin candidates would neither shrink nor grow after adoption of the PREVENT-based guideline. Using data from 1999-2020 and limited to adults age 40-79 years, investigators found that the proportion of individuals who may be recommended lipid-lowering therapy was 49.6% with the 2026 guideline versus 49.4% before the guideline, according to Allison Peng, MD, of Johns Hopkins University School of Medicine in Baltimore, and colleagues.
“Notably, there was no significant net change in statin recommendation, suggesting that risk recalibration with PREVENT-ASCVD does not translate into fewer people recommended for evidence-based preventive therapy at the population level,” the authors wrote.
Nonetheless, while the pool of overall statin candidates would stay about the same — perhaps shifting more lower-risk — the higher-risk cohorts were in fact the ones still furthest away from their LDL cholesterol goals, related to underuse of lipid-lowering therapy.
A third JAMA study took NHANES cycles 2021-2023 and found larger gaps in LDL cholesterol control with higher cardiovascular risk: among people age 30-79 in the primary prevention cohort, the proportion of people above the LDL cholesterol goal was an estimated 9.9% among PREVENT-estimated low-risk adults, 63.6% among borderline/intermediate-risk adults, and 82.7% among high-risk adults.
“These findings provide a contemporary population-level benchmark for the updated guideline framework,” wrote Shady Abohashem, MD, MPH, of Massachusetts General Hospital and Harvard Medical School in Boston, and colleagues.
Altogether, the three studies “confirm the long-standing observation that a large percentage of U.S. adults aged 30 years or older are candidates for guideline-directed LLT [lipid-lowering therapy], and many who are currently taking LLT are not reaching new (or previous) LDL-C goals,” observed JAMA editors Philip Greenland, MD, of Northwestern University Feinberg School of Medicine in Chicago, and Karen Lasser, MD, MPH, of Boston Medical Center.
“This is a huge public health burden for the U.S. population for a medical condition that should be highly treatable,” they wrote in an editorial. “Given the large numbers of people who would be recommended for treatment following a risk-based discussion, these reports signify a major challenge, and so far, a missed opportunity, for the U.S. healthcare system.”
Efforts to improve lipid treatment and control will require several fronts, they said, citing approaches such as multidisciplinary teams, patient education regarding statins and the new guidelines, and the policy of universal health insurance.
For one, statins remain key medications for high cholesterol, given their long history and accessibility. A growing number of nonstatin alternatives are available now, however, including the first oral PCSK9 inhibitor enlicitide (Lipfendra) for lowering LDL cholesterol, approved just a few days ago by the FDA.
Individual decision making will involve considering side effects, costs, and patient preferences, Anderson suggested.
“Many of my younger patients wonder why they can’t put off starting treatment — which is understandable, given they might have low risk of a cardiovascular event 10 years out — and some likely can with a strong focus on healthy diet, exercise, and weight. But for patients seeking to fully minimize risks of heart attacks and strokes, early statin therapy may be a good choice,” he said.
