There’s been a lot of talk about chronic diseases lately and rightly so. Heart disease, for instance, kills more Americans every year than any other condition. What has received far less attention is how the medical community is changing its approach to prevent it.
This month, the American College of Cardiology, American Heart Association and nine other medical organizations released a comprehensive revision to their 2018 guidance on how to manage high cholesterol, one of the leading causes of heart disease. These new recommendations — which will affect medical care for millions of Americans by emphasizing earlier, more proactive treatments — mark a meaningful step in the right direction.
High cholesterol, specifically elevated levels of low-density lipoprotein (LDL) cholesterol, has long been recognized as a major driver of heart attack and stroke. Yet prior guidance focused on estimating a person’s cardiovascular disease risk over the next 10 years to determine when to begin treatment and did not set clear target levels for LDL cholesterol.
Perhaps the most consequential change in the new guidelines is the move to consider not only a patient’s 10-year risk but also their 30-year risk. The guidelines endorse a risk calculator known as PREVENT, which uses factors including blood pressure, cholesterol levels, diabetes status and smoking history to estimate both medium- and long-term risk.
This is important because someone with a low 10-year risk might have a high 30-year risk and should consider lipid-lowering treatment. This reflects the reality that plaque builds gradually in the arteries over time, and that earlier intervention can reduce the cumulative exposure to harmful cholesterol that drives this process.
The second crucial difference is that the updated guidance sets clear targets for cholesterol levels. Specifically, most people should aim for a level below 100 milligrams of LDL cholesterol per deciliter of blood. For those with a 10 percent or greater risk of having a significant cardiovascular event in the next 10 years, the goal drops to below 70 milligrams. And those who already have cardiovascular disease has an even lower target of below 55. These thresholds reflect growing consensus that reducing LDL earlier and maintaining it at lower levels leads to substantially greater protection against heart attack and stroke.
The guidelines also encourage starting screening much earlier than many people realize. Cholesterol testing isn’t just for middle-aged and older adults. In fact, it is now recommended for all children between ages 9 and 11 to identify inherited conditions such as familial hypercholesterolemia, which affects about 1 in 250 people worldwide. Screening should resume in late adolescence and continue at least once every five years thereafter.Those found to have persistently high LDL or other major risk factors for heart disease may need to begin cholesterol-lowering treatment as early as age 30.
Meanwhile, additional tests can better refine risk, as the new guidelines explain. One that stands out is a test to detect lipoprotein(a), a type of cholesterol not measured in standard lipid panels and that is largely genetic. An estimated 64 million Americans have elevated lipoprotein(a) levels, which increases the risk of cardiovascular disease by as much as threefold.
One advantage of this testing is that because lipoprotein(a) remains relatively stable during adulthood, it generally needs to be measured only once. While there is not yet a specific treatment to address this cholesterol, identifying elevated levels can be a wake-up for people who did not know they were at high risk to more aggressively address other cardiovascular risk factors.
The guidelines also expand the tools to clarify risk when the clinical picture is uncertain. For some patients, a coronary artery calcium scan, a specialized CT scan that looks for calcified plaque in the arteries supplying the heart, can detect early buildup and help guide decisions about whether to begin medication. Additional blood markers, such as apolipoprotein B, a protein that carries cholesterol in the blood, may also be useful for some people to better personalize treatment decisions.
Finally, when it comes to treatment, the recommendations affirm that statins remain the foundation of cholesterol-lowering therapy. These medications have nearly 40 years of evidence supporting their effectiveness and are widely available as low-cost generics. For those who can’t take statins or who need further lipid reduction, additional options are available, including newer oral agents and injectable therapies. Importantly, the guidelines also make clear that dietary supplements such as fish oil, turmeric, cinnamon and garlic are not appropriate alternatives to medication treatment.
Taken together, these changes represent a fundamental shift in how clinicians think about cholesterol. For patients, this proactive approach can be empowering. They can enter their information into the PREVENT calculator to better understand their risk and can inquire about tests to have more informed conversations with their clinicians about treatments.
And they can address factors that promote cardiovascular health. The real promise of these guidelines is not just better prediction but earlier and more effective action to reduce risk. That includes medications and well as lifestyle changes, including maintaining a healthy weight, avoiding tobacco and excess alcohol, staying physically active and following a heart-healthy diet.
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