Changes in statin therapy eligibility under the 2026 versus 2018 dyslipidemia guidelines.

Background: The 2026 ACC/AHA Dyslipidemia Guideline replaced the 2018 guideline and adopted PREVENT-ASCVD as the preferred primary prevention risk framework. Although prior analyses applying PREVENT-ASCVD alone suggested that statin eligibility may decrease because of lower absolute risk estimates compared with the Pooled Cohort Equations, the population-level impact of the full 2026 guideline framework remains unclear. Methods: We analyzed adults from the 2017-2020 National Health and Nutrition Examination Survey to assess statin eligibility under the 2018 and 2026 ACC/AHA guideline frameworks. Survey weights generated nationally representative estimates. Participants were classified as eligible under both guidelines, eligible only under the 2018 guideline, eligible only under the 2026 guideline, or ineligible under both. We estimated overall and subgroup-specific changes in eligibility and used logistic regression to identify factors associated with new eligibility under the 2026 guideline. Results: Among a weighted population of 77.8 million U.S. adults aged 30-79 years (N = 2747), statin eligibility increased from 39.8% under the 2018 guideline to 54.3% under the 2026 guideline, representing 11.2 million additional eligible adults and a 36.2% relative increase. Most adults were classified similarly under both guidelines, while 16.5% were newly eligible and 2.1% lost eligibility. The largest relative increase occurred among adults younger than 50 years. Greater age, sex, greater body mass index, higher total cholesterol, lower eGFR, current smoking, and hypertension were associated with new eligibility. Conclusions: The 2026 ACC/AHA Dyslipidemia Guideline substantially expanded statin eligibility, reflecting the full updated eligibility framework rather than PREVENT-ASCVD alone. Expanded eligibility will require implementation strategies to improve statin access, uptake, and long-term ASCVD prevention.