Millions more Americans now eligible for statins. What new cholesterol guidelines mean

WASHINGTON — An estimated 21.5 million additional adults in the United States may now be eligible for statins under updated cholesterol treatment guidelines, according to a new study.

The researchers aimed to estimate how many adults in the U.S. would be considered eligible for statin therapy under the new 2026 blood cholesterol guidelines issued by the American Heart Association, the American College of Cardiology and nine partnering medical societies, compared with the previous 2018 guidelines.

The analysis, published July 20 in the journal JAMA, found that the changes could bring the total number of Americans eligible for statins, medications that lower cholesterol, to about 87.5 million people, or more than half of adults ages 30 to 79.

What prompted this major expansion, and does being eligible mean that someone should immediately begin taking medication? Dr. Leana Wen. Wen, an emergency physician and clinical associate professor at George Washington University, explained the study and what patients should discuss with their healthcare providers.

Who are the millions of Americans who are newly eligible

Wen said the team analyzed data from more than 4,300 participants in a national health survey collected between 2017 and 2023. The sample was designed to represent about 154 million American adults ages 30 to 79 who did not already have known cardiovascular disease.

The researchers applied both the old and new guidelines to the same population.

"More than 21 million adults who were not previously recommended statins would become eligible under the new guidance, the study authors found," Wen said. "Altogether, an estimated 87.5 million adults, or nearly 57% of the population studied, would be eligible for statin therapy for what's called primary prevention, which aims to prevent a first heart attack, stroke or other cardiovascular event."

Why the update

There are four major changes that significantly expanded eligibility, the doctor explained.

1. The age range for cardiovascular risk assessment increased. The earlier guidelines focused primarily on adults ages 40 to 75. The new recommendations apply risk estimation to adults ages 30 to 79.
2. The guideline lowered the thresholds used to categorize cardiovascular risk. Under the new recommendations, someone is considered at high risk with a 10% chance of having a cardiovascular event over the next 10 years, intermediate risk at 5% and borderline risk at 3%.
3. The guidelines now give greater weight to certain medical conditions. For instance, adults ages 40 to 75 with more advanced chronic kidney disease or with HIV may qualify for statins.
4. The updated guidelines place greater emphasis on long-term cardiovascular risk. For instance, someone with less than a 3% chance of developing cardiovascular disease over the next 10 years may still be considered for a statin if their estimated 30-year risk is at least 10%.

What to do with low estimated risk

"Cardiovascular disease develops gradually because LDL or low-density lipoprotein, often called 'bad' cholesterol, can build up inside artery walls over decades and form plaques that increase the risk of heart attack and stroke," Wen said, adding that a 40-year-old could have a low chance of a cardiovascular disease largely because of their younger age, but this does not necessarily translate to their overall lifetime risk being low.

The new guidelines incorporate 30-year risk estimates for adults ages 30 to 59.

"The goal is to identify people who may benefit from reducing cholesterol earlier rather than waiting until their 10-year risk becomes high," Wen said.

Not all who are newly eligible should take a statin, the doctor said. "Eligibility means that statin therapy should be considered," she emphasized.

"The decision should be individualized and based on factors including age, smoking status, family history, medical conditions and tolerance for taking a daily medication," Wen said.

"The first step is to know your numbers," Wen said, which includes a recent lipid panel, which measures your total cholesterol and triglycerides, as well as other factors in your medical history such as whether you have diabetes, high blood pressure, or other medical conditions such as kidney disease and HIV. The American Heart Association's PREVENT calculator can estimate the chance of developing cardiovascular disease over 10 years and, for many younger adults, over 30 years.

Additional blood tests, including measuring levels of lipoprotein(a) and apolipoprotein B, can also refine risk.

Patients should discuss treatment options with their own doctors.

Benefits, side effects of statins

Statins are among the most extensively studied medications in medicine, Wen explained, adding that most people tolerate them well.

Statins can also modestly increase blood sugar and the likelihood of developing diabetes, especially in people who already have risk factors for diabetes, she said. However, for someone at substantial cardiovascular risk, the reduction in heart attacks and strokes generally outweighs this small increase in diabetes risk.

"Lifestyle measures remain essential for everyone," Wen said. "A heart-healthy eating pattern emphasizes vegetables, fruits, whole grains, legumes, nuts, fish and other minimally processed foods. Regular physical activity, maintaining a healthy weight, controlling blood pressure and managing diabetes also reduce cardiovascular risk, as does stopping smoking and limiting excess alcohol.

It may be reasonable for some with moderate risk to focus first on lifestyle changes and then reassess cholesterol levels and overall risk. For others, especially those with very high LDL or multiple major risk factors, lifestyle changes should accompany medication.

The central message of the new guidelines is that "cholesterol management should begin earlier and be tailored more closely to both a person's short- and long-term risk," Wen said. "This is not to say that half of American adults should automatically leave their next appointment with a prescription; rather, it's a call for more people to have conversations with their primary care clinicians about what kinds of measures can help prevent cardiovascular disease years before it could occur."

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