A Paradigm Shift in Lipid Management: Highlights from the NLA 2026 Scientific Sessions Opening Session

At the opening session of the National Lipid Association (NLA) 2026 Scientific Sessions, James A. Underberg, MD, MS, MNLA, discussed what he described as a transformative "new standard of care" in cardiovascular health. Discussing the freshly released Multi-Society Dyslipidemia Guidelines, Underberg outlined a shift toward earlier intervention, personalized risk assessment, and the restoration of rigorous lipid targets.¹

Lower for Longer: A New Tenet of Care

The 2026 guidelines are built upon 4 core pillars: screening earlier, checking regularly, aiming for lower low-density lipoprotein cholesterol (LDL-C) levels, and treating for longer durations. Underberg emphasized that managing lipids is no longer just about a single snapshot of a patient's current levels, but rather the "area under the curve," or the cumulative lifetime exposure to atherogenic lipoproteins.¹

“It’s not about what the LDL is today, but what’s the exposure to high cholesterol along with how that’s been modified by additional risk factors,” Underberg told the audience. To support this, the guidelines now recommend universal lipid screening as early as 9 to 11 years of age, with repeat checks at 19 years and at least every 5 years thereafter.^1,2

The PREVENT Era and the CPR Framework

A major technical highlight of the session was the formal transition from the older Pooled Cohort Equations to the PREVENT risk calculator. This more contemporary model allows clinicians to estimate both 10-year and 30-year cardiovascular risks starting at age 30, rather than age 40. The PREVENT tool also integrates more nuanced data, including hemoglobin A_1C (HbA_1C), ZIP code-based social determinants of health, and kidney function.^1-3

Underberg introduced the CPR framework to guide clinical decision-making:

• C: Calculate 10-year risk using PREVENT.
• P: Personalize risk using "risk-enhancing factors," such as family history or reproductive history.
• R: Reclassify risk using selective tools such as coronary artery calcium (CAC) scoring or specialized testing.

The Return of Targets: LDL and Apolipoprotein B

In a move that aligns American standards with European guidelines, the 2026 update restores explicit LDL-C goals. These targets are now tiered by risk²:

• Less than 100 mg/dL for primary prevention in patients with low risk (<10%).
• Less than 70 mg/dL for those with familial hypercholesterolemia, diabetes with risk factors, or intermediate risk.
• Less than 55 mg/dL for secondary prevention in "very high-risk" patients with atherosclerotic cardiovascular disease (ASCVD).

Notably, Apolipoprotein B (ApoB) has been elevated from a mere risk enhancer to a formal treatment target. Underberg noted that ApoB is particularly useful when LDL measurements become less accurate at very low levels or in patients with diabetes and hypertriglyceridemia.^1,2 Additionally, the guidelines now recommend that Lipoprotein(a) should be measured at least once in all patients to identify individuals with high inherited risk.^1,2

A Comprehensive Toolbox

The 2026 guidelines signal a definitive departure from a "statin-only" mindset, moving instead toward a goal-oriented strategy that utilizes a broad array of pharmacological tools. Although statins remain the foundation of therapy, particularly in primary prevention and for patients with elevated triglycerides, the new standards fully integrate nonstatin therapies to help patients reach increasingly aggressive targets.^1,2

Underberg highlighted that for secondary prevention and very high-risk individuals, clinicians should readily employ ezetimibe (Zetia; Merck), PCSK9 inhibitors, bempedoic acid (Nexletol; Esperion), and inclisiran (Leqvio; Novartis) to bridge the gap between current levels and target goals. This "toolbox" approach is most visible in the newly established management protocol for homozygous familial hypercholesterolemia.^1,2

For patients who are considered high risk, the guidelines recommend an immediate move to aggressive triple therapy—combining a statin, ezetimibe, and a PCSK9 inhibitor—before considering specialized treatments such as evinacumab (Evkeeza; Regeneron), lomitapide (Juxtapid; Chiesi), or LDL apheresis. The objective is to ensure that even the most challenging cases can achieve an LDL goal of less than 100 mg/dL, or as low as 55 mg/dL if ASCVD is already present.^1,2

Conclusion: A Lifetime Perspective on Prevention

The overarching message of the NLA 2026 session was one of proactive, lifetime management rather than reactive treatment. By moving the formal risk-assessment threshold down to 30 years of age and replacing older models with the PREVENT calculator, the medical community is now equipped to identify and mitigate cardiovascular risk decades earlier than previous standards allowed. Underberg noted that this shift allows health care professionals to move the conversation away from a single laboratory snapshot and toward the area under the curve, focusing on reducing the cumulative lifetime exposure to harmful lipoproteins.

Ultimately, these guidelines aim to simplify the specialty into 2 primary objectives: reducing cardiovascular events and preventing pancreatitis. By restoring explicit lipid targets and elevating ApoB to a formal treatment goal, the 2026 guidelines provide a clear roadmap for personalized care. As the session concluded, the consensus among the experts was clear: by embracing a "lower for longer" philosophy and treating earlier, clinicians can significantly reduce the "prolonged exposure to atherogenic lipoproteins" and prevent poor health outcomes later in life.¹

REFERENCES

1. Underberg J, Johnson H, Peña J. Lower for longer: lipid management in an era of evolving science. Presented at: National Lipid Association (NLA) 2026 Scientific Sessions. June 11, 2026; Chicago, IL.

2. 2026 ACC/AHA/AACVPR/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of dyslipidemia: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. 2026;153(17). doi:10.1161/CIR.00000000001423

3. The American Heart Association PREVENT Online Calculator. Accessed June 11, 2026. https://professional.heart.org/en/guidelines-and-statements/prevent-calculator