Updated cholesterol guidelines may give some adults a different answer to an important question: How likely am I to have a heart attack or stroke?
While the shift doesn’t mean high cholesterol has suddenly become more or less dangerous for these groups, it could change what treatments your doctor recommends, says Eric J. Brandt, MD, director of preventive cardiology and an assistant professor at the University of Michigan Medical School in Ann Arbor, who wasn’t involved in creating the new tool.
“When someone moves from one category to another, then this may change the recommended approach to prevention,” says Dr. Brandt.
Why the Old Heart Risk Calculator Needed an Update
Doctors use cardiovascular risk calculators to estimate a person’s chances of having a heart attack, stroke, or another problem caused by plaque buildup in the arteries. That score can help guide decisions about cholesterol-lowering medication.
The calculator used for more than a decade was based on five groups of people recruited from the 1940s through the 1980s. Later studies suggested the calculator overestimated risk in some groups, including men and Black adults, and did not characterize risk as accurately in other populations.
“The advantage of the new tool is that the data used to estimate the effect of each variable represent a more modern population that’s larger and more diverse,” says Brandt.
The 2026 cholesterol guidelines replace the older calculator with the PREVENT tool, which:
- Was developed using data from 46 larger, more contemporary, and more diverse studies
- Is race-agnostic, meaning race is not entered into the calculation
- Includes additional health information, such as kidney function and body mass index
- Can estimate both 10- and 30-year cardiovascular risk for adults ages 30 to 79
About 1 in 5 Adults Got a Different Risk Estimate
The new analysis, published in JAMA, included health information from nearly 25,000 U.S. adults aged 40 to 79 without known heart disease. Researchers calculated each person’s 10-year risk using both the old calculator and the PREVENT tool.
Comparing the results, they found:
- About 79 percent of adults stayed in the same risk category.
- About 14 percent moved into a lower-risk category.
- About 7 percent moved into a higher-risk category.
Women and adults with diabetes were the groups most likely to move up. Specifically:
- About 20 percent of adults with diabetes moved into a higher-risk category, while 8 percent moved down.
- About 11 percent of women moved up, while 5 percent moved down.
Factors Behind the Shifts
Men, non-Hispanic Black adults, and current smokers were more likely to move into lower-risk groups. Because previous studies found that the old calculator tended to overestimate risk in these populations, the downward shifts may reflect better calibration, rather than a reduction in the dangers of smoking, high blood pressure, or high cholesterol, says lead author Allison Peng, MD, a cardiovascular disease fellow at Johns Hopkins Medicine in Baltimore.
The study authors are less certain why the upward shifts happened. For people with diabetes, the difference may reflect changes in the health of the American population since the older calculator was developed, says Dr. Peng. For example, more adults today have heart disease risk factors, and more people are living with multiple co-occurring health conditions, she explains.
It’s not clear why women moved upward more often, says Peng. The new guidelines recommend that doctors consider risk enhancers such as pregnancy complications and early menopause when a woman’s initial score does not provide a clear answer about treatment, but those aren’t included in the new PREVENT calculation.
A Different Risk Score Could Change Your Care
A different category can affect whether a doctor recommends medication, additional testing, or continued monitoring.
“[The new tool] helps with shared decision-making with the patient,” says Nishant Shah, MD, an associate professor of medicine and researcher at the Duke University School of Medicine in Durham, North Carolina, who wasn’t part of this new analysis. “It sets the stage for the conversation on where the patient stands in terms of risk from a population standpoint.”
Under the new guidelines, cholesterol-lowering medication is generally recommended when the estimated 10-year risk is 5 percent or higher. Doctors and patients may consider medication when the risk is between 3 and 5 percent, depending on other factors such as family history and other medical conditions, and the individual’s preferences, Brandt says.
Additional tests may also be performed to estimate risk, including a coronary artery calcium scan, which looks for plaque in the heart’s arteries, or a lipoprotein(a) blood test, which can add information about inherited cardiovascular risk. Dr. Shah recommends that adults have lipoprotein(a) checked at least once in their lives.
Your LDL Cholesterol Goal Depends on Your Overall Risk
PREVENT estimates the likelihood of a major cardiovascular event, but the guidelines also provide LDL “bad” cholesterol goals to aim for once treatment is started.
According to Shah, the main targets are:
- Below 100 milligrams per deciliter (mg/dL) for people at lower risk.
- Below 70 mg/dL for people at high risk.
- Below 55 mg/dL for people with heart disease who are at very high risk of another event.
People in borderline or intermediate categories may need additional assessment before a doctor decides how low their LDL should go, he says.
Many adults currently have LDL levels that are too high, according to the new goals. An accompanying editorial reported that about 32 percent of adults trying to prevent a first heart attack or stroke had high LDL cholesterol. That rose to nearly 83 percent among those at the highest risk, and almost 80 percent of adults with established heart disease had inadequately controlled cholesterol levels.
Strengths and Limitations of the Study
A key strength was the large, nationally representative sample, which allowed researchers to estimate how the new approach could affect different demographic and health groups.
But the study examined how people moved between risk categories. It didn’t follow them to determine whether PREVENT predicted actual heart attacks and strokes more accurately than the old tool. Researchers also couldn’t explain why particular groups moved up or down, and the analysis included only adults ages 40 to 79, even though PREVENT can be used beginning at age 30.
What to Ask Your Doctor About Your Cholesterol Risk
“It is always a good idea to be proactive rather than reactive when it comes to cardiovascular health,” Shah says.
He suggests asking your doctor:
- Is my cardiovascular risk being managed as well as it could be?
- What should my individual LDL cholesterol goal be?
- How can I reach that goal, and do I need additional testing to define my risk more accurately?
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