• The 2026 cholesterol guideline has many critics on social media.
• A speaker addressed the critiques of the cholesterol guideline and rebutted them.

SCOTTSDALE, Ariz. — Criticism of the 2026 American Heart Association/American College of Cardiology/Multisociety Guideline on the Management of Dyslipidemia abounds on social media.

A speaker at the American Society for Preventive Cardiology Congress on CVD Prevention decided to take all of it on at once.

In the guise of social media critics, Ann Marie Navar, MD, PhD, FAHA, FACC, FASPC, associate professor of medicine in the division of cardiology at UT Southwestern Medical Center, went through the common critiques of the guideline on social media, and then as herself, she rebutted them.

Critique: Follow the money. If the experts all agree, someone must be paying them.

“No big pharma company that we think about is getting rich off of statins anymore,” Navar said. “And the reality is that if we got everybody on statins before they had complicated plaque, it would probably be the worst thing possible for big pharma’s bottom line. But if anybody is profiting on statins ... it’s [pharmacy benefit managers] who manage to get a 50% markup on every dollar that is spent on generic therapy.”

Critique: There are no randomized trials of statins in young people.

“Lack of a decades-long randomized controlled trial is not the same as a lack of evidence,” Navar said. “But the reality is we’re never going to be able to support a decades-long cardiovascular outcomes trial in young people. The events are too rare. However, we have so many lines of evidence for benefit of lipid-lowering therapy early in life. We have causal biology that shows that LDL particles are foundational to the development of atherosclerosis. We have multiple studies showing that cumulative exposure to elevated LDL levels over the lifespan increases cardiovascular risk. We have genetic studies in both directions. People with genetic mutations that increase LDL have more heart disease, and people with genetic mutations that lower LDL have less. And we have clinical trials that have shown consistent benefit for statins and other therapies for lowering LDL, regardless of age or baseline cardiovascular risk. We have yet to find a threshold of LDL or a risk that is too low, below which we do not see a benefit for statin therapy or lipid-lowering.”

Critique: They want statins for everyone. Nine in 10 people won’t have an event for 30 years, so let’s treat them all.

“Although the annual incidence of cardiovascular events in young people is smaller than in older people, as you get older, your risk of events goes up,” Navar said. “There are far more people in the U.S. that are between the ages of 40 and 50 than any other age group. And when we look at the total number of cardiovascular events that occur in the United States, about half of events in men and one-third of cardiovascular events in women occur before the age of 65. Premature cardiovascular disease is not rare. In fact, it is almost the majority of cardiovascular events that we are seeing. Some say young people don’t want to take pills. And I’m calling BS on that. And I think the best evidence that we have for that is the number of people every day that pop pills and supplements to try to keep themselves healthy. We do have a communication problem here, but we need to stop kidding ourselves and giving ourselves a pass for why we’re not treating young people with medications by saying they don’t want to take pills. They do. Seven in 10 young people are taking a pill to live longer. Now, imagine the population benefit if we could get everybody on an unproven supplement and get them on a statin instead.”

Critique: The guidelines are too complicated. Patients and primary care professionals can’t handle this.

“This is just a ridiculous criticism of primary care,” Navar said. “Here are the lipid guidelines in a single table. Low to intermediate risk, LDL less than 100 mg/dL. High risk, LDL less than 70 mg/dL. Very high risk, less than 55 mg/dL. Three numbers, it’s not that hard. Oh, we made it too complicated with non-HDL and [apolipoprotein B]? OK, I can simplify this for you too. Non-HDL is LDL plus 30. And then ApoB is the same as LDL, but take away 10.”

Critique: Your brain needs cholesterol. Lowering it via statins harms your brain.

“Your brain’s cholesterol levels are decoupled from your blood cholesterol level,” Navar said. “And the content of cholesterol in the brain is largely independent of the systemic circulation. And further, we’ve actually tested the cognitive safety of lipid lowering directly. In a pooled analysis of randomized trials of statins that have evaluated global cognition in over 20,000 people, [there was] no difference in cognitive outcomes in patients on statins. And we know from genetic studies that the few of us in the United States that are fortunate enough to get a double knockout of PCSK9 and live your entire life with almost no circulating PCSK9 and very low LDL cholesterol levels, there’s one side effect, and it isn’t cognitive. It’s that you live longer.”

Critique: Statins don’t save lives.

“In fact, we have data from the Cholesterol Treatment Trialists’ Collaboration that show a 10% reduction in all-cause mortality per millimoles per liter reduction in LDL cholesterol,” Navar said.

Critique: Stop wasting your time with more testing.

“The EISNER trial randomized over 2,000 people to a [coronary artery calcium] score or not, and found that those who were randomized to CAC testing had better blood pressure, LDL and weight loss with no increase in downstream testing,” Navar said. “We recently looked at this in more contemporary data using MarketScan data. We did see that about 7% of people after a CAC scan get some sort of additional test within a month of that CAC scan. Now, many of those may have had symptoms that prompted the test. Most of those were actually stress ECGs, not particularly invasive. There was no increase in angiography or bypass surgery. But what we did see was a huge increase in statin use, a greater than 10% bump in statin initiation after having a CAC scan. There is no better tool to motivate patients to take therapy.”