Top 10 Concepts in Secondary ASCVD Prevention From the 2026 ACC/AHA Dyslipidemia Guideline: What Is New and Why It Matters.

PURPOSE OF REVIEW: The 2026 American College of Cardiology/American Heart Association (ACC/AHA) dyslipidemia guideline represents a major shift in secondary prevention of atherosclerotic cardiovascular disease (ASCVD), moving beyond a predominantly low-density lipoprotein cholesterol (LDL-C)-centered model toward earlier, lower, longer, and more individualized lipid-lowering strategies. This review summarizes 10 practice-changing concepts from the guideline with direct relevance to patients with clinical ASCVD. RECENT FINDINGS: Despite high-intensity statin therapy, substantial residual cardiovascular risk may persist because of delayed treatment intensification, persistent apolipoprotein B (apoB)-containing lipoprotein burden, elevated lipoprotein(a) [Lp(a)], triglyceride-rich remnants, and high-risk cardiovascular-kidney-metabolic (CKM) comorbidities. Major updates include reintroduction of goal-directed therapy, lower LDL-C and non-high-density lipoprotein cholesterol (non-HDL-C) targets, and broader use of non-statin therapies, including ezetimibe, proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, bempedoic acid, and inclisiran. In patients with clinical ASCVD at very high risk, LDL-C and non-HDL-C targets of < 55 mg/dL and < 85 mg/dL, respectively, are recommended. The guideline also emphasizes structured lipid monitoring and a systematic approach to statin-attributed muscle symptoms to reduce therapeutic inertia, preserve effective lipid-lowering therapy, and support sustained goal attainment. Collectively, these updates mark a transition toward precision lipidology, emphasizing individualized risk assessment, earlier treatment escalation, structured follow-up, preservation of effective therapy despite treatment-related symptoms, and more comprehensive reduction of residual cardiovascular risk in secondary prevention.