Navigating the 2026 Cholesterol Guidelines With John Bucheit, PharmD

As the American College of Cardiology's 2026 annual meeting gets underway, updated lipid management guidelines are generating significant discussion among clinicians. Pharmacy Times spoke with John Bucheit, PharmD, BCACP, an associate professor at VCU School of Pharmacy, to break down the most meaningful changes—from the return of LDL-C targets to new risk calculators, earlier intervention strategies, and the evolving role of apolipoprotein B in risk assessment.

Pharmacy Times: The 2026 guideline marks a shift back to LDL-C targets. What drove the decision to move away from the previous threshold-based approach?

John Bucheit, PharmD, BCACP: The new LDL targets are more practical. From a practicing clinician's perspective, it's helpful to have a specific number to discuss with patients, and it's helpful for patients to know where they need to go with their LDL and non-HDL cholesterol. This helps both the patient and the clinician make a decision about how aggressive we want to be with lipid-lowering therapy. With that said, the patients who are going to benefit the most are those who achieve the largest absolute reduction in LDL and non-HDL cholesterol—so an absolute reduction in those measures remains important.

Pharmacy Times: The PREVENT ASCVD calculator addresses prior concerns about risk overestimation. How do you expect this to change treatment decision-making in practice?

Bucheit: The new PREVENT ASCVD risk calculator has been validated and studied in a large, modern population, which has meaningfully improved our ability to estimate risk. The pooled cohort equation was a good step, but this calculator offers broader and more current validation. What's also notable is that it can be applied to patients as young as 30 years of age, allowing us to better identify risk earlier — and prevention is always the goal. Additionally, this calculator provides a 30-year risk estimate. Even if a patient's 10-year risk appears low, the 30-year risk may still factor into a shared decision-making conversation about initiating treatment.

Pharmacy Times: How does apolipoprotein B (ApoB) enhance risk assessment beyond traditional lipid measures, and when should it be prioritized?

Bucheit: There's been considerable discussion about ApoB in these new guidelines. LDL and HDL remain our primary treatment targets; however, the guidelines do identify specific patient populations in whom measuring ApoB should be considered—including patients with high triglycerides, diabetes, or other select conditions. This will be an individualized decision between the clinician and patient. In these populations, there may be discordance between LDL measures and ApoB, which is an important consideration when trying to ensure we've adequately addressed a patient's residual risk.

Pharmacy Times: The emphasis on earlier intervention, even in childhood, is notable. What evidence supports this shift?

Bucheit: Early intervention is important. I want to take a step back and note that approximately 1 in 250 people have familial hypercholesterolemia—a condition that is significantly underdiagnosed. Being able to better identify even young adults or children with this condition is meaningful. The guidelines assign this a category B-R level of evidence, indicating moderate evidence from randomized controlled trials or meta-analyses supporting screening in these populations. We also have FDA-approved medications for use in patients under 18, which provides reassurance regarding their safety profile. The first step for these patients will still be lifestyle modification; pharmacotherapy is considered when clinically indicated, and we have good randomized controlled trial evidence supporting its safety.

Pharmacy Times: What are the biggest barriers to implementing these updated recommendations in clinical practice?

Bucheit: The biggest barriers are awareness and education. In terms of pharmacotherapy, while there are therapies in these guidelines not present in the 2018 update, many of those medications have already been approved for several years. The more significant changes are the return of specific LDL targets and the new risk assessment tools—such as the PREVENT ASCVD calculator, CAC scoring, and ApoB measurement—and helping clinicians understand how to incorporate these into everyday practice. We're here at ACC 2026, and we'll continue to see data reinforcing the importance of lipid targets. The field will keep evolving, but the immediate challenge is making sure both our cardiology colleagues and primary care providers are aware of and aligned with these new recommendations.