★ New — LDL-C Calculation(Class I, all adults & children)
Martin/Hopkins or Sampson/NIH are preferred over Friedewald (and over direct LDL-C measurement, except beta-quantification). Friedewald underestimates LDL-C when TG > 150 or LDL < 70 mg/dL — the exact range that drives treatment.
Sampson/NIH (closed-form): LDL-C = (TC ÷ 0.948) − (HDL ÷ 0.971) − [TG ÷ 8.56 + (TG × non-HDL) ÷ 2140 − TG² ÷ 16100] − 9.44
Martin/Hopkins: LDL-C = TC − HDL − (TG ÷ adjustable factor); divisor comes from a 180-cell lookup of non-HDL × TG strata (range ~3.1–11.9). Most US labs now report one or both automatically. An interactive version of both calculators is included on page 2 of this guide.
Primary Prevention — Risk-Based Treatment (PREVENT-ASCVD)
Adults 30–79 without ASCVD or subclinical disease; LDL-C 70–189 mg/dL
Risk Category10-yr ASCVDStatin RecommendationLDL-C / non-HDL-C Goal
Low< 3%Counseling only (if LDL-C < 160; 30-yr risk < 10% applies ages 30–59)—
Low (elevated)< 3% with LDL 160–189 OR 30-yr ≥ 10%Consider moderate-intensity statinBorderline goals
Borderline3% – < 5%Consider moderate-intensity statin; use enhancers/CACLDL < 100 · non-HDL < 130
Intermediate5% – < 10%≥ Moderate-intensity (high-intensity at upper range)LDL < 100 · non-HDL < 130
High≥ 10%High-intensity statin ± ezetimibe; add PCSK9 mAb / bempedoic acid if goal not metLDL < 70 · non-HDL < 100
Secondary prevention — ASCVD—High-intensity statin; add ezetimibe, PCSK9 mAb, or bempedoic acid as neededLDL < 70 · non-HDL < 100 (consider < 55 / < 85)
Very-high-risk ASCVD*—Max statin + ezetimibe and/or PCSK9 mAb; inclisiran if PCSK9 mAb not tolerated/availableLDL < 55 · non-HDL < 85 · ApoB < 55 (optional)
Coronary Artery Calcium (CAC) — Men ≥ 40, Women ≥ 45
CAC Score (Agatston)ActionGoals
0Defer statin; repeat CAC in 3–7 yr. Exceptions: FH, severe ↑LDL, DM + age > 40, current smoker, or strong family history of premature ASCVDLifestyle
1–99 or < 75th %ileModerate-intensity statinLDL < 100 · non-HDL < 130
100–299 or ≥ 75th %ileStatin first-line LLTLDL < 70 · non-HDL < 100
300–999Statin; consider intensificationLDL < 70 (consider < 55) · non-HDL < 100 (consider < 85)
≥ 1000Treat like established ASCVDLDL < 55 · non-HDL < 85
When to Order CAC
Order (COR 1): intermediate risk (5 – < 10%) or selected borderline risk (3 – < 5%) when statin decision is uncertain.   Consider (COR 2a): intermediate or high risk on therapy when LLT intensity is uncertain — CAC refines goals.
Useful also in: younger adults with strong family history of premature ASCVD or elevated Lp(a); patients who prefer to avoid statins; incidental CAC on non-gated CT (COR 1).   Do NOT use to "de-risk" FH, severe ↑LDL, established ASCVD, or DM meeting criteria — they qualify for statin regardless.
Practice Pearls & Special Populations

Screening Pearls

  • Non-fasting lipid panel acceptable for screening & routine monitoring.
  • Measure Lp(a) at least ONCE in every adult (Class I).
  • ApoB useful in patients on LLT, esp. ASCVD, T2DM, CKM, or ↑TG.
  • Confirm lab reports Martin/Hopkins or Sampson — not Friedewald.

PREVENT Replaces PCE

Use the PREVENT-ASCVD equations for 10- and 30-year risk in adults 30–79 without ASCVD. More accurate across race/sex; incorporates kidney & metabolic risk. PREVENT is required for the risk thresholds in the table above.

Lp(a) Thresholds

  • ≥ 125 nmol/L (50 mg/dL): risk-enhancer (~1.4×).
  • ≥ 250 nmol/L (100 mg/dL): ~2× ASCVD risk.
  • Elevated Lp(a) + ASCVD not at goal on max statin → add PCSK9 mAb.

Not Recommended (COR 3)

Dietary supplements should NOT be used to lower LDL-C or TG (limited, inconsistent data; no proven ASCVD benefit). Examples discussed in the guideline include red yeast rice, fish oil for LDL lowering, and plant sterols.

Triglyceride Management

  • 150–499 (primary prevention): PREVENT risk + lifestyle; consider statin.
  • ≥ 150 with ASCVD off LDL/non-HDL goal on max statin: intensify LDL-lowering first.
  • ≥ 500 (esp. ≥ 1000 despite diet): lifestyle + fibrate or high-dose omega-3 reasonable (COR 2a).
  • ≥ 1000: aggressive TG-lowering; refer to RDN; olezarsen for familial chylomicronemia syndrome.

Statins remain the foundation across all TG categories.

Severe ↑LDL / Suspected FH

  • LDL ≥ 190 mg/dL: high-intensity statin; add ezetimibe, PCSK9 mAb, and/or bempedoic acid based on residual gap.
  • Inclisiran reasonable if LDL ≥ 100 mg/dL on max statin ± ezetimibe.
  • Do NOT apply 10-/30-yr risk tools in HeFH.
  • Genetic panel reasonable if LDL ≥ 190 without secondary cause; cascade-screen first-degree relatives.

Diabetes Quick Cuts

  • Age 20–39: moderate-intensity statin may be reasonable (COR 2b) if long-duration DM + albuminuria, eGFR < 60, retinopathy, neuropathy, or ABI < 0.9.
  • Age 40–75: moderate-intensity statin, goal LDL < 100; high-intensity if multiple risk factors (goal LDL < 70).
  • Icosapent ethyl may be considered (COR 2b) if LDL < 100, TG 150–499 on statin, and additional ASCVD risk factor(s).
  • Refer to lipid specialist for HoFH, refractory LDL on triple therapy, multi-statin intolerance, TG ≥ 1000, or for inclisiran/evinacumab/lomitapide.
*VHR ASCVD: ≥ 2 major ASCVD events OR 1 major event + ≥ 2 high-risk conditions (age > 65, CABG/PCI, smoking, DM, HF, HTN, or LDL > 100 on max statin+ezetimibe).   Source: Blumenthal et al., 2026 ACC/AHA Dyslipidemia Guideline (Circulation 2026).

Interactive LDL-C Calculator — Martin/Hopkins & Sampson/NIH

mg/dL
mg/dL
mg/dL
Non–HDL-C (TC − HDL) — mg/dL
Martin/Hopkins LDL-C 2026 ACC/AHA
— mg/dL
VLDL = TG ÷ adjustable factor
Sampson/NIH LDL-C 2026 ACC/AHA
— mg/dL
Closed-form polynomial
Martin/Hopkins: LDL = TC − HDL − (TG ÷ adjustable factor); factor from a 180-cell lookup of non-HDL × TG strata (range 3.1–11.9).
Sampson/NIH: LDL = (TC ÷ 0.948) − (HDL ÷ 0.971) − [TG ÷ 8.56 + (TG × non-HDL) ÷ 2140 − TG² ÷ 16100] − 9.44

PREVENT-ASCVD Risk Calculator — AHA 2024 Base Equations

Sex
yr
mg/dL
mg/dL
mmHg
kg/m²
ml/min
Optional — upgrades to augmented model when entered
mg/g
%
Model: Base
10-yr ASCVD Risk
— %
Primary endpoint · 2026 LLT thresholds
30-yr ASCVD Risk
— %
Ages 30–59: refines low 10-yr risk
10-yr Total CVD Risk
— %
ASCVD + HF · HTN Stage 1 threshold ≥7.5%
Low risk — 10-yr ASCVD < 3%
Lifestyle counseling. If age 30–59 and LDL-C < 160 mg/dL and 30-yr risk < 10%: no statin indicated. Reassess in 4–6 yr.
Low risk — elevated exposure
10-yr < 3% but LDL-C 160–189 or 30-yr ASCVD ≥ 10% (ages 30–59). Consider moderate-intensity statin to reduce cumulative atherogenic burden.
Borderline risk — 10-yr ASCVD 3% to <5%
Consider moderate-intensity statin after clinician–patient discussion. Risk-enhancers (Lp(a), hsCRP, ABI) or CAC can tip toward treatment. Goal: LDL < 100 · non-HDL < 130 mg/dL.
Intermediate risk — 10-yr ASCVD 5% to <10%
At least moderate-intensity statin recommended (COR 1); high-intensity at upper range or with risk enhancers. Consider CAC if statin decision uncertain. Goal: LDL < 100 · non-HDL < 130 mg/dL (≥30% LDL-C reduction).
High risk — 10-yr ASCVD ≥ 10%
High-intensity statin recommended (COR 1). Add ezetimibe if LDL-C goal not met; add PCSK9 inhibitor or bempedoic acid if still above goal. Target: LDL < 70 · non-HDL < 100 mg/dL (≥50% LDL-C reduction).
⚠ PREVENT is validated for ages 30–79. Values outside this range should be interpreted with caution.
Source: Khan SS et al. Development and Validation of the American Heart Association's PREVENT Equations. Circulation 2024;149:430–449. Base model (no UACR/HbA1c/SDI). Logistic regression; risk = eLP/(1+eLP). Centered at: age 55 yr, non-HDL-C 3.5 mmol/L, HDL-C 1.3 mmol/L, SBP 130 mmHg, BMI 25 kg/m², eGFR 90 ml/min. Not valid in known ASCVD, HeFH/HoFH, LDL < 70 or ≥ 190, or age < 30/> 79.