People at risk of heart disease should start trying to lower their cholesterol as early as age 30 and continue into old age. They should also be getting their cholesterol levels lower than many doctors had previously recommended.
That is the new guidance released Friday by the American Heart Association and nine other professional organizations.
The hope is to reduce the toll of cardiovascular disease, which is responsible for about one in three deaths in the United States.
“Eighty percent or more of cardiovascular disease is preventable,” said Dr. Roger Blumenthal, chairman of the guideline writing committee and a cardiologist at Johns Hopkins Medical School.
If the new guideline were widely followed, especially by younger people who could end up with a lifetime of lower LDL levels, there could be a big effect, cardiologists say.
“Heart disease would go down markedly,” Dr. Blumenthal said. “We think we could cut heart attack and stroke rates down by half.”
The group recommends starting to test for levels of LDL cholesterol — the “bad” cholesterol — during childhood, at around age 10. Doing so could identify the one in 250 people with a genetic condition that leads to extremely high cholesterol levels. They would need to be immediately prescribed a cholesterol-lowering drug.
Doctors should also test patients around ages 18 to 20 and repeat the screening at least every five years. It should be done more often for those with high LDL levels or other risk factors like diabetes.
Treatment goals for those 30 and older depend on risk. Everyone should strive for an LDL level below 100, the guideline says. Those with at least a 10 percent risk of having a heart attack or stroke in the next 10 years should get their LDL below 70. Those who have already had a heart attack or stroke, or who have peripheral artery disease, should get their LDL below 55.
High levels of LDL cholesterol are a major contributor to heart disease risk, experts say. And the longer people live with elevated LDL levels, the more likely it is that they will develop heart disease.
The average LDL level in the United States is 110, but 25 percent of the population has an LDL level above 130.
“A key message from these guidelines is that lower LDL means lower risk, and we now have tools to get people to levels we couldn’t reach before,” said Dr. Harlan Krumholz, a Yale cardiologist not involved with developing the guideline.
Other cardiologists who were not involved in developing the guideline also praised it.
“The guidelines have finally caught up that lower is better for longer,” said Dr. Steven Nissen, a cardiologist at the Cleveland Clinic who consults for makers of heart drugs but does not accept compensation.
Dr. Christopher Cannon, a cardiologist at Brigham and Woman’s Hospital, said the new guideline was evidence-based medicine and “a fantastic advance” for patients. He consults for companies making heart disease drugs.
The advice is a departure from the previous guideline, published in 2018, which did not set firm LDL level recommendations for people with varying degrees of risk for a heart attack or stroke. And that guideline calculated risk as the chance of having a heart attack or stroke only in the next 10 years.
Calculating risk over the next 30 years is important, cardiologists said, because someone age 30 or 40 is unlikely to have a high 10-year risk but might have a high 30-year one. And the way to prevent heart attacks and strokes is to reduce lifetime exposure to dangerous LDL levels, they said.
The first approach for lowering LDL levels should be lifestyle: diet and exercise. While most people cannot make a significant difference in their LDL level with this approach, Dr. Blumenthal said, for some it turns out to be all they need.
But there is a growing list of medications that can lower LDL levels. Statins — cheap, generic LDL-lowering pills — work for most, but there are also drugs that can be taken in addition to statins. Those drugs can be used by people who cannot tolerate or will not take statins, as well as by those who need to get their LDL lower than can be achieved by statins alone.
The guideline also says people should not rely on supplements to lower their LDL. A clinical trial, run by Dr. Nissen, tested six supplements. Five of them — fish oil, cinnamon, turmeric, plant sterols and red yeast rice — were no better than a placebo. The sixth — garlic in pill form — actually raised LDL levels.
But deciding who needs lower LDL levels, how to lower them and by how much can require more than just a test of LDL cholesterol levels. The guideline says everyone should be tested once for a protein known as Lp(a) which can independently make heart disease more likely.
Almost no one is tested now for Lp(a), said Dr. Leslie Cho, a cardiologist at the Cleveland Clinic who helped write the new guideline and consults for makers of heart drugs.
“If it’s high, we would treat your LDL very aggressively,” Dr. Cho said.
Gina Kolata reports on diseases and treatments, how treatments are discovered and tested, and how they affect people.
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