The new cholesterol guidelines advise doctors to start screening and treating people starting at age 30, long before the risks of heart attack or stroke increase significantly.
For the first time, the American Heart Association, along with the American College of Cardiology and other medical groups, also recommends screening for two blood biomarkers that have been linked to heart risks.
The updated guidelines were jointly published this Friday in Circulation and in the Journal of the American College of Cardiology.
The guidelines — the first revision since 2018 — focus on managing dyslipidemia, or abnormal levels of blood lipids such as cholesterol and triglycerides.
One in four American adults has an elevated level of LDL, or “bad” cholesterol, a form of dyslipidemia and a risk factor for heart attack and stroke, according to estimates by the heart association.
“We’re trying to help doctors and patients decide: When should medication be considered?” said Dr. Roger Blumenthal, chair of the guideline writing committee and director of the Ciccarone Center for Cardiovascular Disease Prevention at Johns Hopkins University in Baltimore. “We always want to strive to improve lifestyle habits with each visit, but sometimes medication can be very helpful if changing habits doesn’t work.”
Dr. Christopher Kramer, a cardiologist at UVA Health Heart and Vascular Center in Charlottesville, Virginia, said the most important takeaway from the new guidelines is that heart disease prevention needs to start sooner. Kramer is also president of the American College of Cardiology, but was not part of the guidelines writing committee.
“We are changing the way we measure risk,” he said. “We not only evaluated the risk at 10 years, but also at 30 years, which brings us back to the fact that this is a lifelong disease.”
Reducing LDL cholesterol throughout life
For patients between 30 and 39 years old, doctors are now recommended to use a new calculation tool, PREVENT, to determine the risk of developing atherosclerotic cardiovascular disease, a type of heart disease caused by the buildup of plaque in the arteries.
The PREVENT tool, which takes into account factors such as body mass index, cholesterol levels and tobacco use, ACCalculate the risk over 10 years for people aged 30 to 79 years and the 30-year risk for people aged 30 to 59 years. The updated 10-year risk categories are:
- Low: less than 3%.
- Limit: 3% to 5%.
- Intermediate: from 5% to less than 10%.
- High: 10% or more.
Blumenthal said the new guidelines will be especially important for people who smoke, have hypertension, hyperglycemia, type 2 diabetes or a family history of heart disease.
“It gives them context about the importance of whether or not they should be more aggressive with lifestyle changes from the beginning,” he said.
The guidelines recommend statins, a type of medication designed to lower cholesterol, for adults age 30 and older with LDL cholesterol levels of 160 milligrams per deciliter of blood or higher.
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Dr. Steven Nissen, academic director of the Sydell and Arnold Miller Institute for Cardiology, Vascular and Thoracic Surgery at the Cleveland Clinic, said early intervention aims to limit long-term exposure to LDL cholesterol.
“Average lifetime LDL cholesterol is one of the most reliable predictors of having a cardiovascular event,” said Nissen, who was not part of the guideline writing committee. “It’s really about reducing lifetime risk, not 10-year risk.”
In his opinion, previous versions of the guidelines were too conservative. He was more pleased with the new recommendations, which advise doctors to consider LDL-lowering treatment in patients with borderline or intermediate 10-year heart disease risks.
“This is much lower than ever,” Nissen said. “Basically what they’re saying is don’t rule out treating someone who only has a 3% 10-year risk if their lifetime risk is high.”
Clear LDL goals
Dr. Karol Watson, director of the Women’s Cardiovascular Center at UCLA Health, co-authored a commentary published in Circulation along with the new guidelines, which he described as an expansion of the previous version.
“This is not a radical change; “We continue to control lipids to reduce atherosclerotic events,” she said. “As a preventive cardiologist, I can tell you that is the best strategy we have had so far to prevent heart attacks, strokes and cardiovascular death.”
The new guidelines offer “a more precise, individualized, and equitable approach” to heart disease prevention, Watson wrote in the commentary.
The guidelines restore clear targets for LDL cholesterol. For most people without risk factors, doctors now aim for LDL levels below 100 mg/dL.
For high-risk people, the goal drops below 70 mg/dl. For patients who already have heart disease, the goal is even lower, below 55 mg/dl.
Research shows that people with heart disease have fewer heart attacks and strokes when treated with an LDL goal of less than 55 mg/dL.
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However, individual cholesterol tolerance can vary, Watson said, citing a very active 70-year-old patient of his who had always had low cholesterol but still suffered a mini-stroke.
“Everyone knows someone whose cholesterol was very, very high and who lived to be 90 years old,” he said. “Every person has their own level at which their arteries allow cholesterol in.”
Additional Biomarker Testing
The new guidelines also suggest testing for apolipoprotein B (apoB), a protein that binds to harmful fat particles in the blood, once the patient has reached their LDL goal. The apoB protein is found on the surface of harmful lipoproteins such as LDLwhich contribute to heart disease.
Previous guidelines did not recommend routine apoB testing as part of cholesterol screening, except in some patients with elevated triglycerides.
“That could be yet another target to further lower lipids, since lowering apoB is associated with lower risk,” Kramer said.
In particular, apoB testing may provide a clearer picture of risk in people with elevated triglycerides, type 2 diabetes, or cardiovascular-renal-metabolic syndrome.
Everyone needs to get tested for Lp(a), at least once
Also new this year is the recommendation that everyone get tested for lipoprotein(a) at least once in adulthood. Lp(a) is a type of cholesterol that is not detected in routine tests, but is estimated to affect 64 million people in the US. It is determined by genetics and is hardly affected by changes in diet or exercise
People with elevated Lp(a) levels are at extremely high risk of cholesterol buildup in the arteries.
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“It should be considered a factor that increases the risk,” Nissen said. “If your levels are high, it means you may need more intensive treatment, even if your LDL is not as high as you would expect.”
Lp(a) is measured in nanomoles per liter. A level above 250 nmol/L is equivalent to approximately a two-fold increase in the risk of heart disease, while a level above 430 nmol/L indicates a four-fold increased risk.
“There are currently no treatments available to lower Lp(a), so many people are asking, ‘Well, why am I getting tested?'” Watson said. “The main reason is to get a better overall risk assessment.”
The new guidelines also recommend screening for calcium buildup in the coronary arteries in men age 40 and older and women age 45 and older who have a borderline or intermediate 10-year risk of heart attack or stroke.
Regardless of the change in screening guidelines, the risk factors for heart disease remain the same.
“They are cholesterol, blood pressure, diabetes, smoking and obesity,” Kramer said. “People should focus on rreduce your risk factors and let their doctors do the math and decide whether or not they need cholesterol-lowering medication.
Heart disease is the leading cause of death worldwide. In the US, one person is killed every 34 seconds, according to the American Heart Association. However, the organization also estimates that up to 80% of heart disease and stroke can be prevented with lifestyle changes.
“If you wait until people turn 55 or 60, a lot of the damage has already been done,” Nissen said. “They have plaques in their coronary arteries and it is difficult to reverse the problem.”
