Heart Disease Prevention: Which Tests, and When

In March 2026 the ACC, AHA and nine other societies replaced the 2018 cholesterol guideline. Two changes matter most for anyone thinking about their own risk: lipoprotein(a) should now be measured at least once in every adult’s lifetime, and lipid screening starts at 19 and repeats every five years regardless of risk.

What does the 2026 guideline recommend measuring?

Four things, in sequence.

A lipid panel, fasting or non-fasting, every five years from age 19, plus one screening in childhood between 9 and 11. This is a departure from the largely risk-based approach of previous guidelines, made on the reasoning that cumulative lifetime exposure to atherogenic lipoproteins drives risk, not just individual events.

Lp(a), once. It is genetically determined and stable across life, so a single measurement suffices and lifestyle changes barely alter it. The guideline describes Lp(a) at or above 125 nmol/L (roughly 50 mg/dL) as elevated, associated with about 1.4-fold higher long-term risk, and levels at or above 250 nmol/L as very high, associated with roughly double the risk. It raises cardiovascular risk independently of LDL-C.

A PREVENT-ASCVD risk estimate, replacing the older Pooled Cohort Equations, calculating 10-year risk for adults aged 30 to 79 and, for adults aged 30 to 59, a 30-year risk as well. Categories are low (under 3%), borderline (3% to under 5%), intermediate (5% to under 10%) and high (10% or above).

Coronary artery calcium, selectively. A non-contrast CAC scan is recommended for men 40 and older and women 45 and older at borderline or intermediate risk, when the result would change the decision about starting a statin. Any detectable calcium supports an LDL-C goal below 100 mg/dL.

ApoB, selectively, for people with cardiovascular-kidney-metabolic syndrome, type 2 diabetes, high triglycerides or known cardiovascular disease, once LDL-C and non-HDL-C goals are met.

Why did the guideline move earlier?

Because the model of risk changed. The guideline is framed around lifetime exposure rather than short-term event probability, which is why it screens younger, why it adds a 30-year risk horizon for people in their thirties, forties and fifties, and why it reintroduced numeric LDL-C targets that the 2018 version had replaced with percentage reductions.

Not everyone agrees on the screening expansion. The US Preventive Services Task Force has concluded that evidence remains insufficient for some of these recommendations, and that disagreement is worth knowing about. Which tests apply to any individual, and how to actually track the results over time, is a decision for a clinician who knows the full picture.

The bottom line

• Lp(a) is now recommended at least once in every adult’s lifetime
• Lipid screening starts at 19 and repeats every five years, regardless of risk category
• Coronary artery calcium scanning is recommended selectively, for men 40+ and women 45+ at borderline or intermediate risk, when it would change the treatment decision