Cardiology · AHA

Dyslipidaemia management

AHA

Source:2026 ACC/AHA/AACVPR/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Dyslipidemia

Verified Apr 2026

Ask House about this guideline

Red Flags

Familial hypercholesterolaemia features (LDL-C ≥190 mg/dL, tendon xanthomas, or premature CAD family history) — refer for genetic testing and high-intensity statin^[1]
Triglycerides ≥1000 mg/dL — risk of acute pancreatitis, urgent triglyceride-lowering therapy required^[1]
ASCVD with progression despite maximally tolerated statin — evaluate for PCSK9 inhibitor or inclisiran^[1]
Lipoprotein(a) ≥125 nmol/L (≥50 mg/dL) — independent ASCVD risk enhancer warranting intensified lifestyle and lipid-lowering therapy^[1]

First-line treatment

Interventions

Heart-healthy lifestyle from childhood^[1]
Mediterranean or DASH-pattern diet, ≥150 min/week moderate aerobic activity, weight reduction if BMI ≥25, smoking cessation, alcohol limitation. Earlier intervention emphasized in 2026 update

First-line drug therapy

Drug	Class	Adult	Paediatric	Notes
Atorvastatin^[1]	HMG-CoA reductase inhibitor (statin)	40–80 mg PO once daily (high-intensity for ASCVD or LDL-C ≥190); 10–20 mg (moderate-intensity for primary prevention)	10 mg once daily for ages ≥10 with familial hypercholesterolaemia	First-line for both primary and secondary prevention; LDL-C goal <55 mg/dL in very-high-risk ASCVD
Rosuvastatin^[1]	HMG-CoA reductase inhibitor (statin)	20–40 mg PO once daily (high-intensity); 5–10 mg (moderate-intensity)	5 mg once daily for ages ≥10 with familial hypercholesterolaemia	Alternative statin; preferred with statin intolerance to atorvastatin or in renal impairment
Ezetimibe^[1]	Cholesterol absorption inhibitor	10 mg PO once daily	10 mg once daily for ages ≥10	Add when LDL-C goal not reached on maximally tolerated statin; provides additional ~20% LDL-C reduction
Evolocumab^[1]	PCSK9 inhibitor (monoclonal antibody)	140 mg SC every 2 weeks OR 420 mg SC monthly	—	For very-high-risk ASCVD or familial hypercholesterolaemia not at LDL-C goal on statin + ezetimibe

Atorvastatin^[1]

HMG-CoA reductase inhibitor (statin)

Adult: 40–80 mg PO once daily (high-intensity for ASCVD or LDL-C ≥190); 10–20 mg (moderate-intensity for primary prevention)
Paediatric: 10 mg once daily for ages ≥10 with familial hypercholesterolaemia

First-line for both primary and secondary prevention; LDL-C goal <55 mg/dL in very-high-risk ASCVD

Rosuvastatin^[1]

HMG-CoA reductase inhibitor (statin)

Adult: 20–40 mg PO once daily (high-intensity); 5–10 mg (moderate-intensity)
Paediatric: 5 mg once daily for ages ≥10 with familial hypercholesterolaemia

Alternative statin; preferred with statin intolerance to atorvastatin or in renal impairment

Ezetimibe^[1]

Cholesterol absorption inhibitor

Adult: 10 mg PO once daily
Paediatric: 10 mg once daily for ages ≥10

Add when LDL-C goal not reached on maximally tolerated statin; provides additional ~20% LDL-C reduction

Evolocumab^[1]

PCSK9 inhibitor (monoclonal antibody)

Adult: 140 mg SC every 2 weeks OR 420 mg SC monthly
Paediatric: —

For very-high-risk ASCVD or familial hypercholesterolaemia not at LDL-C goal on statin + ezetimibe

Safety-net

Statins are taken lifelong — stopping causes LDL-C to rebound and cardiovascular risk to climb back rapidly^[1]
Mild muscle aches are common and usually not serious; severe muscle pain, weakness, or dark urine — stop the statin and seek care^[1]
Routine liver function and CK are not required unless symptoms develop — do not let lab fears delay therapy^[1]

Referral criteria

Triglycerides ≥1000 mg/dL with abdominal painEmergency department — risk of acute pancreatitis^[1]
Suspected familial hypercholesterolaemia (LDL-C ≥190, tendon xanthomas, premature CAD family history)Lipid clinic for genetic testing and family cascade screening^[1]
Established ASCVD not at LDL-C goal <55 mg/dL on maximally tolerated statin + ezetimibeCardiology or lipid clinic for PCSK9 inhibitor or inclisiran^[1]
Lp(a) ≥125 nmol/L with personal or family history of premature ASCVDLipid clinic for risk-enhancer-aware management^[1]

Clinical summary

Evaluation and management of elevated cholesterol, hypertriglyceridaemia, and elevated lipoprotein(a) for primary and secondary cardiovascular prevention.

References

1.2026 ACC/AHA/AACVPR/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Dyslipidemia (2026)

Drug

Class

Adult

Paediatric

Notes

Atorvastatin^[1]

HMG-CoA reductase inhibitor (statin)

40–80 mg PO once daily (high-intensity for ASCVD or LDL-C ≥190); 10–20 mg (moderate-intensity for primary prevention)

10 mg once daily for ages ≥10 with familial hypercholesterolaemia

First-line for both primary and secondary prevention; LDL-C goal <55 mg/dL in very-high-risk ASCVD

Rosuvastatin^[1]

HMG-CoA reductase inhibitor (statin)

20–40 mg PO once daily (high-intensity); 5–10 mg (moderate-intensity)

5 mg once daily for ages ≥10 with familial hypercholesterolaemia

Alternative statin; preferred with statin intolerance to atorvastatin or in renal impairment

Ezetimibe^[1]

Cholesterol absorption inhibitor

10 mg PO once daily

10 mg once daily for ages ≥10

Add when LDL-C goal not reached on maximally tolerated statin; provides additional ~20% LDL-C reduction

Evolocumab^[1]

PCSK9 inhibitor (monoclonal antibody)

140 mg SC every 2 weeks OR 420 mg SC monthly

—

For very-high-risk ASCVD or familial hypercholesterolaemia not at LDL-C goal on statin + ezetimibe