New Cholesterol Guidelines Expand Statin Eligibility

An estimated 21.5 million more adults in the U.S. may now qualify for statin medication, according to a recent study based on updated cholesterol treatment guidelines.

The study aimed to determine how many adults would be eligible for statins under the new 2026 blood cholesterol guidelines released by the American Heart Association and other medical institutions, compared to the previous 2018 guidelines.

Published in the journal JAMA, the findings suggested that these changes could increase the number of eligible Americans for statin treatment to approximately 87.5 million, which represents over half of adults aged 30 to 79.

So, why this significant increase in eligibility? Does it mean everyone should start taking medication immediately? To shed light on this, I spoke with Dr. Leana Wen, an emergency physician and clinical associate professor at George Washington University. She previously served as Baltimore’s health commissioner.

CNN: Who are these newly eligible Americans and why?

Dr. Leana Wen: The research analyzed data from over 4,300 participants in a national health survey conducted between 2017 and 2023. This sample aimed to reflect around 154 million American adults aged 30 to 79 without known cardiovascular disease.

The researchers applied both the old and new guidelines and found that over 21 million adults, who weren’t previously recommended for statins, qualify under the new guidance. Overall, about 87.5 million adults—or nearly 57% of the studied population—would be considered for statin therapy as a preventive measure against a first heart attack, stroke, or other cardiovascular events.

CNN: Why do the revised guidelines make so many more individuals suitable for statin therapy?

Wen: There are four main changes that expanded eligibility significantly. First, the age range for assessing cardiovascular risk has been broadened; the earlier guidelines primarily looked at adults aged 40 to 75, while the new recommendations assess risk for those aged 30 to 79.

Secondly, the updated guidelines have lowered the thresholds that determine cardiovascular risk. Now, a person is considered at high risk if they have a 10% chance of experiencing a cardiovascular event in the next 10 years, intermediate risk at 5%, and borderline risk at 3%.

Third, the guidelines place greater focus on certain medical conditions. For example, adults aged 40 to 75 who have more advanced chronic kidney disease or HIV may now qualify for statins.

Finally, the new guidelines emphasize long-term cardiovascular risks more. For instance, someone with less than a 3% chance of developing cardiovascular disease over the next decade might still be considered for a statin if their estimated 30-year risk is at least 10%.

CNN: Many of the newly eligible adults have a low estimated risk over the next decade. Why might treatment still be recommended?

Wen: Cardiovascular disease develops slowly; LDL, or “bad” cholesterol, can accumulate in artery walls over decades, forming plaques that elevate the risk of heart attack and stroke. A 40-year-old might show a low chance of developing cardiovascular disease in the next decade due to their youth, but their lifetime risk could still be significant. Elevated LDL, high blood pressure, diabetes, smoking history, or strong family history can make their long-term risk much higher.

As such, the new guidelines incorporate 30-year risk estimates for adults aged 30 to 59, aiming to identify individuals who could benefit from preventative cholesterol reduction earlier rather than waiting until their 10-year risk spikes.

CNN: Does being eligible under these guidelines mean that someone has to start taking a statin?

Wen: No, being eligible suggests that statin therapy should be contemplated, but not that it’s mandatory for everyone.

Individuals at a higher risk, like those with very high LDL or diabetes, should seriously consider starting statin therapy. Others should make decisions based on a variety of factors such as age, smoking habits, family history, and overall health conditions.

A younger adult with a low chance of a heart attack over the next decade might take a different approach compared to an older adult with the same LDL levels but a significantly higher near-term risk.

CNN: How can people find out if they’re among those newly eligible?

Wen: First, it’s important to know your cholesterol numbers through a recent lipid panel, which measures total cholesterol, LDL, HDL, and triglycerides, alongside medical history factors like diabetes and high blood pressure. Healthcare professionals can input this data into the American Heart Association’s PREVENT calculator, which estimates risks of developing cardiovascular disease over 10 years, and, for younger adults, over 30 years.

Your healthcare provider might suggest additional tests, such as a coronary artery calcium scan, which looks for calcified plaques in the arteries that supply the heart. This can be particularly helpful for individuals at borderline or intermediate risk. A higher calcium score indicates the presence of plaque and can strengthen the case for treatment. A zero score may suggest that it could be wise to delay or avoid statin therapy, although age and other risk factors need consideration.

Further blood tests measuring lipoprotein(a) and apolipoprotein B can provide more refined risk assessments, but these are generally useful when decisions are unclear after analyzing standard risk indicators.

CNN: What should patients ask their healthcare providers before deciding on treatment?

Wen: Start by asking what specific health aspects qualify you for treatment. This helps clarify whether the recommendation is based on cholesterol numbers, calculated risk, other medical conditions, or a mix.

Additionally, inquire about the expected benefits. Rather than just asking if a statin will reduce cholesterol, consider asking, “What is my risk of heart attack or stroke over the next 10 or 30 years, and how much will treatment likely mitigate that risk?”

It’s also wise to ask how your treatment will be monitored, which may include checking cholesterol levels again after starting the medication, assessing symptoms, and adjusting dosages if needed.

CNN: What are the benefits and potential side effects of statins, especially for those who could take them for years?

Wen: Statins are among the most researched medications out there. Generally, people tolerate them well. The most frequently noted side effect is muscle pain or weakness. Interestingly, some individuals who experience symptoms with one statin might tolerate another, possibly with a lower dose or different schedule.

Statins can also modestly increase blood sugar levels and the likelihood of developing diabetes, particularly for those already at risk. Still, for individuals at substantial cardiovascular risk, the decrease in heart attacks and strokes often outweighs this slight uptick in diabetes risk.

A more nuanced scenario arises with younger, lower-risk individuals who might be on medication for decades. Their immediate chances of preventing a heart attack or stroke are comparatively smaller, thus the potential side effects and the burden of long-term treatment are more influential in their decision-making.

CNN: How do lifestyle changes fit into these guidelines?

Wen: That’s a key point. Lifestyle changes are vital for everyone. A heart-healthy diet emphasizes vegetables, fruits, whole grains, nuts, fish, and minimally processed foods. Regular exercise, maintaining a healthy weight, managing blood pressure, controlling diabetes, avoiding smoking, and limiting alcohol intake can all help lower cardiovascular risk.

Some individuals with moderate recommendations for statins may do well to focus on lifestyle changes first, then reassess their cholesterol levels and overall risk later. However, for others with very high LDL or multiple serious risk factors, lifestyle alterations should happen alongside medication.

The essence of the new guidelines is that cholesterol management should begin earlier and be customized to an individual’s short- and long-term risk factors. This doesn’t mean that half of American adults will walk out of their next appointment with a prescription. Instead, it’s a push for more discussions with primary care practitioners about preventative measures that can be taken long before problems arise.