Dyslipidaemia LDL-C, Non-HDL-C, ApoB Treatment Goals (2026)

The 2026 guideline re-introduces absolute treatment goals — a major change from 2018, which had largely moved away from goals. Treatment is now anchored to both absolute goals AND % LDL reduction, with ApoB as a secondary target.

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Step 1 — Identify the patient's goal category

The treatment goal depends on why the patient is on LLT. Match to one of these groups:

Group	Trigger	Default goal (before CAC)
Severe hypercholesterolaemia — no other risk factors	LDL-C ≥190 mg/dL	LDL <100 mg/dL
Severe hypercholesterolaemia + clinical / genetic FH	LDL-C ≥190 mg/dL + FH criteria	LDL <70 mg/dL (non-HDL <100) + ≥50% LDL reduction
Baseline LDL 70–189 mg/dL + low 10-year risk (<3%)	PREVENT <3% but LLT chosen for other reasons (LDL ≥160, 30-yr risk ≥10%, strong FH, high Lp(a))	LDL <100 mg/dL (non-HDL <130) + ≥30% reduction
Baseline LDL 70–189 mg/dL + borderline (3–<5%)	On LLT after enhancer / CAC assessment	LDL <100 mg/dL (non-HDL <130) + ≥30% reduction
Baseline LDL 70–189 mg/dL + intermediate (5–<10%)	Class 1 moderate-to-high-intensity statin	LDL <100 mg/dL (non-HDL <130) + ≥30–50% reduction (≥50% at the higher end of intermediate)
Baseline LDL 70–189 mg/dL + high (≥10%)	Class 1 high-intensity statin	LDL <70 mg/dL (non-HDL <100) + ≥50% reduction
Diabetes mellitus age 40–75, no clinical ASCVD	Class 1 LLT	LDL <100 mg/dL (≥30–49% reduction); non-HDL <130 mg/dL
Diabetes + multiple ASCVD risk factors	Class 1 high-intensity LLT	LDL <70 mg/dL (≥50% reduction); non-HDL <100 mg/dL

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Step 2 — Modify the goal by CAC score (if performed)

CAC scores further sharpen the LDL and non-HDL goals:

CAC score (AU)	LDL-C goal	Non-HDL-C goal	ApoB goal (if measured)
0	Treatment usually deferred; if treated, baseline goal applies	Baseline	—
1–99 (or <75th percentile)	<100 mg/dL (≥30% reduction)	<130 mg/dL	<90 mg/dL
100–299 (or ≥75th percentile, or moderate-to-severe incidental CAC)	<70 mg/dL (≥50% reduction)	<100 mg/dL	<70 mg/dL
≥300	<70 mg/dL (≥50% reduction)	<100 mg/dL	<70 mg/dL
≥1000	<55 mg/dL	<85 mg/dL	<55 mg/dL

Use the lower (more stringent) of the baseline category goal AND the CAC-modified goal.

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Step 3 — Add ApoB goals once LDL-C and non-HDL-C are met

ApoB is a direct measure of atherogenic particle number. The guideline recommends ApoB testing (Class 2) in adults on LLT with any of:

• Concomitant ASCVD
• Diabetes mellitus
• Cardiovascular-kidney-metabolic (CKM) syndrome
• Elevated triglycerides (≥200 mg/dL)

In these groups, once LDL-C and non-HDL-C goals are achieved, use the ApoB target to guide further intensification:

LDL-C target achieved	ApoB target
<100 mg/dL	<90 mg/dL
<70 mg/dL	<70 mg/dL
<55 mg/dL	<55 mg/dL

ApoB discordance from LDL-C (i.e. LDL-C at goal but ApoB high) → intensify LLT per the ApoB goal.

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Step 4 — Monitor and verify goal achievement

• 4–12 weeks after starting, intensifying, or changing LLT → repeat lipid panel
• Every 6–12 months thereafter once stable
• At each visit confirm:
  • Current LDL-C vs goal (absolute)
  • % LDL reduction from pre-treatment baseline
  • Non-HDL-C vs goal
  • If applicable, ApoB vs goal
  • Adherence, muscle symptoms, LFTs if clinically indicated
  • CPK only if severe myalgia / weakness (not routine)
  • Coenzyme Q10 not recommended as routine prophylaxis
  • Aminotransferase monitoring not routine once stable

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Step 5 — If goals not met, add non-statin therapy

Preferred add-on sequence (adapted from Table 2 of the guideline):

Agent	Expected additional LDL reduction
Ezetimibe 10 mg oral daily	~25% add-on (~20% monotherapy)
PCSK9 mAb — alirocumab, evolocumab SC q2–4 wk	~45–65%
Inclisiran SC — initial, then 3 months, then q6mo	~50%
Bempedoic acid oral daily	~15–20% add-on (~20–25% monotherapy)
Bile acid sequestrant (cholestyramine, colesevelam, colestipol)	~10–30% (may ↑ TG)
Lomitapide oral daily	~40–50% (REMS program; HoFH only)
Evinacumab IV q4wk	~50% (HoFH / severe)

Typical escalation path:

1. Maximally-tolerated statin
2. • Ezetimibe
3. • PCSK9 mAb or inclisiran
4. • Bempedoic acid in statin-intolerant or inadequate response
5. Bile acid sequestrant (avoid if TG elevated)
6. Lomitapide / evinacumab for severe FH

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Guardrails

• The 2026 guideline uses dual goals — absolute AND percent reduction. Meeting the absolute goal with only a 15% reduction from baseline in a high-risk patient is NOT at goal
• Treat to goal, not just "start a statin" — the 2018 approach of "start a statin and move on" is superseded
• ApoB is especially informative in LDL/non-HDL discordance — a patient with LDL at goal but ApoB >90 (goal <90) has residual atherogenic particle burden and needs intensification
• Non-HDL-C captures ALL atherogenic lipoproteins (LDL + VLDL + Lp(a)) — do not ignore non-HDL in favour of LDL alone, especially in high-TG patients
• FH / LDL ≥190 has its own stringent goals regardless of 10-year PREVENT-ASCVD — a young adult with LDL 200 and 10-year risk 2% still needs ≥50% LDL reduction and goal <70
• DM + multiple ASCVD risk factors moves the goal from <100 to <70 — identify these patients proactively
• Lifestyle optimisation is NOT replaced by LLT — diet, exercise ≥150 min/wk, weight management, tobacco abstinence, sleep remain Class 1
• Dietary supplements (garlic, turmeric, red yeast rice, non-prescription fish oil) are NOT recommended for dyslipidaemia management per the guideline
• Do NOT re-check CAC routinely once on LLT — statins can paradoxically increase CAC density by stabilising plaque; serial CAC in treated patients is not a monitoring tool
• CPK testing is only indicated for severe myalgia or weakness, with cessation if levels ≥10 × ULN
• Routine aminotransferase monitoring is not needed once stable

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Related MD2SKILL skills

• prevent-ascvd-risk-calculator-interpretation — the risk score that defines the goal category
• dyslipidemia-cpr-framework-2026 — the full workflow leading to this goal-setting step
• cac-scoring-indication-interpretation-2026 — CAC-modified goals
• lpa-screening-interpretation-cascade — Lp(a) measurement and its interaction with goal-setting
• bemdec-prescribing-guide — bempedoic acid for statin-intolerant or add-on therapy

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Sources

Primary: 2026 ACC/AHA/AACVPR/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Multisociety Guideline on the Management of Dyslipidaemia.

Review used for extraction: Abramov D et al. Primary Prevention of Dyslipidemia: 10 Practice-Changing Takeaways from the 2026 ACC/AHA Multisociety Guideline. Current Atherosclerosis Reports. 2026;28:63. DOI: 10.1007/s11883-026-01437-9. Sections "Key Message 8: Treatment-Statins", "Key Message 9: Dyslipidemia Treatment Goals", and Tables 1 & 2.