2026 summary of latest in cardiovascular risk reduction updates

A lot has changed just this year in medicine and my own practice.

Part 2 of The 2026 ACC/AHA Multisociety Guideline on Dyslipidemia 

This lecture continues my review of the latest guideline update from the American College of Cardiology. It’s ok but they are a bit too far behind what I am now recommending. 

1. They are not using Apo B yet. Still using LDL. It’s ok.

   

   I like apo B for many of the reasons discussed in the Iron DPC blog. Namely: it isn’t affected by nonfasting so logistically much more practical (there are some patients who don’t read directions in portal and go in for blood work after having cream and sugar in their coffee so apo B is invaluable to prevent a wasted blood work review). 

2. Lp(a) is in the guidelines which I am very happy to see. A perfect level is <7. The higher the number goes above that the more risk there is. Everyone should test it once. It isn’t really modifiable so it is not necessary to retest. Some theoretical ways to modify it but what that means is unclear. But even with a negative Lp(a) best practice is still optimize lipids.

3. What are the cardiac/stroke risk factors? Well, unfortunately for us men… being a man is a risk factor. Remember that estradiol is cardioprotective. Women have more estrogen than men up until menopause and then the risk evens out. With optimal estradiol therapy in women we can continue keeping that lower risk of heart attack and stroke. Then always consider the powerful influence of genetic risk and family history. Elevated glucose and a1c or diabetes is the strongest risk for heart disease outside of smoking. Obesity is also in the guidelines as a risk but not visceral fat (fat on the organs which is revealed by imaging such as the dexa body comp, abdominal ultrasound to assess fatty liver or MRI/CT of abdomen however radiologists do not count nor describe visceral fat. There are certain AI programs out there online that can do that and I’ve also learned to identify visceral fat on abdomen MRI or CT myself to help identify risk in patients). At Iron DPC we have long focused on reversing insulin resistance as a cause for cardiac disease. This is very difficult for some patients to reverse because it requires progressive resistance training, HIIT, cardio, and improving the diet. Thankfully the GLP-1 medications have made it possible for some patients to improve their insulin resistance and the GLP-1 medicines now have FDA indications for reversing and preventing cardiac risk and disease and reversing fatty liver disease which essentially means GLP-1s reduce cancer risk since fatty liver is a cause of cancer if left to progress to cirrhosis. The ACC has lowered the numbers necessary to prevent cardiac disease but isn't as aggressive with treatment as Dr. Alo describes in my summary of his blog. 

4.  The #1 cause of death is heart disease. This year I have made it Iron DPC’s purpose to bring attention to this matter as lipid lowering is anti aging medicine. Dr. Alo believes with optimal lipid lowering we can start seeing people reach the age of 130-140 in our lifetime. From Dr. Alo’s research It is possible to reverse coronary artery disease by treating to an LDL<40 or an apo B <65. Achieving such low numbers is only natural for people with a PSK9 mutation. Through Iron DPC I have met one such individual who lives without medication with an LDL of 10-15. For the rest of us this is not possible. It is a paradigm shift in thinking, but over the years I’ve learned that living with a high lipid burden is not smart even if you’re a “LMHR” like myself. Even Nick Norwitz who is an extraordinary lean phd/md researcher started on Ezetimibe/Bempedoic acid recently after his experiment to push his LDL over 700 and proving he had no plaque in his arteries around age 30 with the Cleerly scan described below. However he wasn’t entirely honest about his “study” and did not live the entire 7 years with that high an LDL. Another Keto CTA study didn’t have the results that the keto authors wished and they now had to retract the study. The keto study actually showed 4x-8x an increase in plaque.

5.  You can of course be an N of #1 study as well here at Iron DPC. The new ACC guidelines are advising the CACS. This is an old technology using a CT of the heart to assess calcium buildup in the arteries. It shows hard plaque but not soft plaque. I no longer recommend this at Iron DPC because of this and also because patients who need to be on statins will see increased calcification on the CACS over the years. That’s because statins harden the soft plaque. Calcified plaque is safer than soft plaque which is more prone to rupture. Brevard County has its first Cleerly scanner in Merritt Island. Typically found in LA or Miami (where they charge 3x the price) the cleerly is a CT angiogram with interpretation by a cardiologist and an AI to assess how much plaque has formed. Listen to the intro on the Cleerly scan that Ashley and I attended on the podcast. This video is now only available through this internal link and not visible publicly on  youtube since the rep got in a little hot water with the company for comparing the vastly different prices dependent on geographic location. I’ve asked Dr. Alo about cleerly and he is less impressed with it stating that it does not measure the lumen. It can't truly see inside the arterial wall — Plaque (especially early soft/non-calcified plaque) develops within the wall. 

6. We also are offering the CIMT ultrasound in office. While this is not the guidelines and Dr. Alo does not recommend as it obviously doesn’t measure the plaque in the heart arteries, we offer it for patients who want to do their own N of #1 experiments and are very resistant to the idea of lipid lowering.

In summary, Anti Aging Medicine is Primary Care and primary care involves primary prevention of the #1 killer in the world which is heart attack and stroke. Learning from the latest in cardiology and optimizing lipids it is possible we can eliminate heart attack and stroke by lowering apo B under 65 or getting an LDL below 40 for those with risk factors.