A new study by investigators from Mass General Brigham finds that nearly 1 in 3 U.S. adults without heart disease — and almost 4 in 5 of those who have already had a heart attack, stroke or other cardiovascular event — have LDL, or “bad” cholesterol levels above the goals set by the newly released 2026 American cholesterol guidelines. Additionally, among adults without heart disease who were above target, about 3 in 4 are not receiving any cholesterol-lowering medication. The results are published in JAMA.

“The gap between where the country’s cholesterol levels actually are and where the new guidelines say they should be is much wider than most people realize,” said lead author Shady Abohashem, Harvard Medical School instructor in radiology at Massachusetts General Hospital. “Heart disease remains a leading cause of death in this country, and a large share of heart attacks and strokes are preventable with medications we’ve had for decades. Yet many people who could benefit from treatment aren’t getting any. That is a missed opportunity at the scale of millions.”

The 2026 American College of Cardiology/American Heart Association dyslipidemia guideline introduced a new cardiovascular risk calculator and lowered LDL treatment goals, reflecting evidence that has made increasingly clear that “lower is better” for higher-risk patients.

To assess how the current U.S. population measures up against these updated treatment goals, Abohashem and his colleagues analyzed national data from approximately 2,300 adults aged 30 to 79 years in the National Health and Nutrition Examination Survey 2021-2023, a federally administered survey representative of roughly 178 million U.S. adults.

Under the updated guidelines, the recommended LDL level in the blood varies according to a person’s cardiovascular risk: The higher a person’s overall risk, the lower their LDL should be. For instance, for adults at low risk, an LDL of 160 mg/dL or higher is the level at which the guidelines suggest considering treatment; for those with established heart disease and very high risk of future cardiovascular events, the target is below 55 mg/dL.

The researchers found substantial gaps between the new LDL goals and actual LDL levels in the population. About one-third of U.S. adults without a history of heart attack, stroke, or other cardiovascular events (primary prevention group) had LDL levels above the new recommended goals; among those, about 76 percent were not receiving any cholesterol-lowering medication. The gap widened sharply as risk rose: Among those at the highest cardiovascular risk, about 83 percent were above goal, and roughly half of them were not receiving any cholesterol-lowering medication.

The gap looked different among adults with established heart disease (secondary prevention group). Nearly 4 of 5 were above the recommended goal, but most (roughly 62 percent) were already receiving cholesterol-lowering therapy without reaching the lower targets, pointing to a need for stronger treatment rather than starting a new one. The remaining 38 percent were receiving no treatment at all.

“The good news is we know exactly what works, and the evidence behind these therapies is among the strongest in medicine,” Abohashem said. “But these are really two different problems requiring two different solutions. In people without heart disease, most who are above target aren’t on any cholesterol-lowering medication at all, so the first step is simply starting treatment. Whereas in people who have already had a heart attack or stroke, most are already on a statin but still aren’t reaching the goal. For them, the answer isn’t starting therapy; it’s intensifying it. That might mean a stronger statin, adding a non-statin medication, or considering newer therapies. Recognizing that difference is essential to closing this gap.”

Falling short of LDL treatment goals is a persistent, long-standing problem, the authors note, with multiple contributing factors including limited access to newer medications, gaps in patient awareness, and structural barriers within the health system. The data were collected before the 2026 guidelines were published, so these figures establish a baseline to track progress as guidelines are adopted in practice. Future research will examine whether the gap narrows over time.

“What we’re measuring here is a starting line, not a verdict,” Abohashem stated. “The new guidelines give us a clearer goal than we’ve ever had. For clinicians, that means re-evaluating patients against the updated targets. And for the public, the message is simpler: Know your LDL number, know your personal target, and if you don’t know either, ask your doctor.”