By Jesica Mills, PharmD, ND, MBA, RPh, BCES, BCLS, BCNP 

Why This Matters Now
In March, the American College of Cardiology (ACC) and the American Heart Association (AHA) published updated guideline for the management of dyslipidemia. The 2026 dyslipidemia guideline represents a major shift in cardiovascular risk management from the previous 2018 version. It now expands beyond LDL cholesterol alone to a more comprehensive, risk-based, and goal-directed approach for patients starting at a younger age. 

Key themes include: 

  • Earlier identification and treatment 
  • Broader risk assessment tools 
  • More aggressive lipid targets 
  • Combination pharmacotherapy as standard care 

For pharmacists, this evolution creates a clear opportunity to lead in screening, therapy optimization, and patient education. 

What’s Changed: Key Updates from the 2026 Guideline 

  1. A New Risk Calculator: PREVENT™
    TheAHA developed the PREVENT equation (Predicting Risk of Cardiovascular Disease EVENTs) to screen patients without known cardiovascular disease. It is the first risk tool to combine cardiovascular, kidney, and metabolic health components, while removing race to reduce bias. The PREVENT equation replaces older Pooled Cohort Equation, and is now the preferred tool for estimating cardiovascular risk in adults aged 30–79 using a much larger patient population 

What it does: 

  • Estimates both 10-year AND 30-year cardiovascular risk as a percentage 
  • Incorporates modern population data and broader risk variables 
  • Supports a more personalized approach to treatment decisions 

How to use it clinically (CPR Model): 

  • C – Calculate risk using PREVENT 
  • P – Personalize based on additional factors (family history, social determinants, metabolic health, inflammation, etc.) 
  • R – Reclassify using tools like coronary artery calcium (CAC) scoring when needed, particularly if patients have borderline risk 

Why it matters:
Patients previously considered “low risk” may now qualify for earlier pharmacotherapy intervention, helping reduce lifetime exposure to atherogenic lipoproteins. Other risk is considered for patients with comorbid conditions who may be meeting LDL targets. 

  1. LDL Goals Are Back—and Lower

Specific LDL goals were removed in 2013 but have once again been included. Treatment is now both: 

  • Percentage-based reduction, and 
  • Absolute LDL targets 

Typical goals: 

  • <55 mg/dL → very high-risk patients 
  • <70 mg/dL → high-risk patients 

Non-HDL cholesterol is also emphasized as a secondary target. 

  1. Earlier Treatment Thresholds

Pharmacotherapy is now: 

  • Considered at 3–5% risk (borderline) 
  • Recommended at ≥5% risk (intermediate and above) 

This reflects a shift toward preventing disease progression earlier, rather than waiting for higher-risk status. Treatment may now be recommended for younger adults based on their 30-year risk projections rather than the 10-year risk. 

  1. ApoB andLp(a) Moveinto Routine Practice 

Other markers may be helpful in determining a more nuanced risk level. Apolipoprotein B (ApoB) is a protein found on the particles that deposit cholesterol in artery walls. Overtime, too much ApoB can contribute to plaque buildup. Lipoprotein a, also known as Lp(a), carries cholesterol in the blood. Lp(a) levels are mostly genetically determined. Levels are typically not affected by lifestyle changes, but there are some secondary causes of high Lp(a).  

  • ApoB helps identify residual risk, even when LDL appears controlled 
  • Lp(a) should be measured at least once per lifetime in all adults 

Elevations in these markers often justify more aggressive therapy. 

  1. Coronary Artery Calcium (CAC) Is Central

Coronary calcium can be seen on a CT scan of the heart looking for calcium deposits in the arteries. Higher amounts of calcium in the arteries suggest more severe disease as it contributes to plaque buildup over time. CAC scoring is now strongly recommended to: 

  • Refine risk 
  • Guide therapy initiation and intensity 

Even incidental CAC findings on imaging should influence treatment decisions. 

  1. Combination Therapy Is the Standard

Statins continue to be the cornerstone of pharmacotherapy for lipid-lowering, but several new lipid-lowering medications have been approved since the last guideline. Combination therapy to reach more aggressive goals may be initiated earlier, before waiting for lifestyle changes and statin monotherapy to fail. It is still recommended for providers to use a risk-based shared decision-making process. The updated guideline supports earlier use of: 

  • Ezetimibe 
  • PCSK9 inhibitors 
  • Bempedoic acid 
  1. Supplements Are Not Recommended for Lipid Lowering

Dietary supplements are not recommended as primary lipid-lowering therapy due to inconsistent evidence. 

This shifts the focus toward: 

  • Proven pharmacotherapy 
  • Lifestyle interventions 

Pharmacotherapy Deep Dive: Counseling and Side Effects 

Statins (First-Line Therapy) 

Mechanism: Inhibit HMG-CoA reductase → reduce hepatic cholesterol synthesis 

Expected LDL Reduction: ≥50% for high-intensity, 30-49% for moderate-intensity, <30% for low-intensity
Common Side Effects: 

  • Myalgias (most common) 
  • Mild elevations in liver enzymes 
  • Rare: rhabdomyolysis 

Clinical Counseling Points: 

  • Muscle symptoms are often manageable and not always drug-related 
  • Take consistently (time of day depends on statin) 
  • Avoid abrupt discontinuation without provider discussion 
  • Monitor for: 
  • Muscle pain with weakness 
  • Dark urine (rare but serious) 

Pharmacist Pearl:
Rechallenge, dose adjustment, or switching statins can often restore tolerance. 

Bempedoic Acid (Nexletol) 

Mechanism: Inhibits ATP citrate lyase (upstream of where statins work in cholesterol synthesis pathway) 

Expected LDL Reduction: 21-24% as monotherapy; 17-18% when added to a statin 

Best For: 

  • Statin-intolerant patients 
  • Patients needing additional LDL lowering 

Common Side Effects: 

  • Increased uric acid (risk of gout) 
  • Tendon rupture (rare but notable) 
  • Mild increases in liver enzymes 

Clinical Counseling Points: 

  • Monitor for joint pain or swelling (possible gout flare) 
  • Report sudden tendon pain, especially in Achilles tendon 
  • Can be safely combined with statins or used alone 

Pharmacist Pearl:
Useful oral alternative before escalating to injectables. 

PCSK9 Inhibitors (Alirocumab, Evolocumab) 

Mechanism: Increase LDL receptor recycling → significantly lower LDL 

Expected LDL Reduction: 50–60%  

Common Side Effects: 

  • Injection site reactions 
  • Mild flu-like symptoms 
  • Nasopharyngitis 

Clinical Counseling Points: 

  • Administer subcutaneously every 2–4 weeks 
  • Store in refrigerator; allow to reach room temperature before injection 
  • Rotate injection sites 

Pharmacist Pearl:
Ideal for high-risk patients not at goal despite oral therapy or with adherence challenges. 

Lifestyle and Root Cause Considerations 

While medication is a powerful tool, lifestyle changes should still be a core component of a treatment plan. The guideline aligns with a broader understanding of cardiometabolic disease, including: 

  • Insulin resistance 
  • Chronic inflammation 
  • Cardiovascular-kidney-metabolic (CKM) syndrome 

High-Impact Interventions 

Nutrition 

  • Increase fiber, omega-3 intake, and whole foods 
  • Reduce refined carbohydrates and ultra-processed foods 

Movement 

  • Resistance training and post-meal walking 

Sleep and Stress 

  • Address cortisol dysregulation and poor sleep patterns 

How to Position Supplements in 2026 

While supplements are not recommended for lipid lowering alone, they still have a role when positioned appropriately. There is value in clinicians educating patients on the types of evidence which support dietary supplements and addressing patient misperceptions that dietary supplements are safer than FDA-approved medications. 

Appropriate Use in Pharmacy Practice 

Focus on: 

  • Supporting metabolic health 
  • Reducing inflammation 
  • Minimizing medication side effects 
  • Enhancing lifestyle adherence 

Examples of Strategic Use 

  • Fiber → supports glycemic control and satiety 
  • Omega-3s → support inflammation and triglyceride trends 
  • CoQ10 → may help with statin-associated muscle symptoms 
  • Magnesium → supports metabolic and cardiovascular health 

Retail Strategy 

Reframe bundles as: 

  • “Cardiometabolic Support Kits” 
  • “Heart Health Lifestyle Packs” 

These should be positioned as adjuncts to therapy, not replacements. 

 

Pharmacist Action Plan: What to Do Monday 

  1. Identify Patients Earlier
  • LDL ≥160 mg/dL 
  • Diabetes or metabolic syndrome 
  • Family history of premature ASCVD 
  1. Use PREVENT in Practice
  • Incorporate into clinical conversations 
  • Identify borderline and intermediate-risk patients 
  1. Treat to Goal
  • Move beyond “on a statin” 
  • Ensure patients reach LDL and non-HDL targets 
  1. Optimize Therapy
  • Add agents earlier when needed 
  • Address adherence and tolerance 
  1. Expand Clinical Services
  • Lipid screenings 
  • MTM focused on cardiometabolic risk 
  • Therapy optimization consults 

Revenue Opportunities for Community Pharmacy 

  • Point-of-care lipid testing 
  • Cardiometabolic health programs 
  • Lifestyle and supplement support packages 
  • Chronic care management and follow-up services 

Bottom Line 

The 2026 guideline shifts cholesterol management toward: 

  • Earlier intervention 
  • More aggressive treatment targets 
  • Broader risk assessment 
  • Combination therapy to meet targets 

Pharmacists are uniquely positioned to translate these updates into improved patient outcomes and expanded clinical services. 

Quick Summary 

  • PREVENT replaces older risk calculators 
  • LDL goals are lower and goal-based 
  • ApoB and Lp(a) are now routine considerations 
  • CAC scoring guides decision-making 
  • Combination therapy is standard 
  • Supplements should support—not replace—therapy 

References: 

AHA PREVENT Risk Assessment Tool 

Blumenthal RS, et al. 2026 ACC/AHA guideline on the management of dyslipidemia. Circulation. 2026;153:e000–e000. doi:10.1161/CIR.0000000000001423 

About Morris & Dickson
Morris & Dickson is the industry’s largest independent full-line and specialty pharmaceutical distributor with a singular focus on reliable, next-day delivery of drugs and related products to health systems, independent and specialty pharmacies, specialty clinics and infusion centers, and alternative care facilities. Serving pharmacies since 1841, Morris & Dickson continues to grow to meet customers’ needs with a comprehensive inventory of over 35,000 SKUs and a state-of-the-art, 12-acre automated distribution center, located in Louisiana. M&D plans to open a second distribution center designed to support its national and specialty growth in early 2026, located in Olive Branch, MS.  www.morrisdickson.com