New Cholesterol Guidelines Call for More Aggressive Prevention and Earlier Treatment

New guidelines for managing cholesterol call for more aggressive prevention and earlier treatment, including a recommendation that all adults be tested once for lipoprotein(a), a genetic risk marker for heart disease.

The American Heart Association and the American College of Cardiology released the updated guidelines Friday, which aim to expand the tools doctors use to assess cardiovascular risk. Cardiovascular disease is the leading cause of death for men and women in the United States.

"We know 80% or more of cardiovascular disease is preventable and elevated LDL cholesterol, sometimes referred to as 'bad' cholesterol, is a major part of that risk," wrote Dr. Roger Blumenthal, a cardiologist at Johns Hopkins in Baltimore who chaired the guideline writing committee, in a statement.

But knowing your LDL levels alone may not be enough, Blumenthal said. Measuring additional biomarkers, he wrote, "can give a more complete picture of someone's cardiovascular risk and help inform decisions about whether lipid-lowering therapy is needed sooner rather than later."

Among the new recommendations is a one-time lipoprotein(a) test for all adults. This is a simple blood test that's widely available, and increasingly many primary care physicians offer it as part of preventive care.

Because lipoprotein(a) is genetically determined and relatively stable over a lifetime, the test typically needs to be done only once, ideally early in adulthood. Elevated levels signal an inherited risk for heart attacks, strokes and other cardiovascular conditions.

The guidelines also call for wider use of coronary calcium scoring, which is a noninvasive scan that measures calcified plaque in the arteries. They also encourage health care providers to use a risk assessment tool called PREVENT, which can project a patient's 10-year and 30-year risk of heart disease to help guide decisions about starting medication.

Cholesterol-lowering drugs, known as statins, remain the first-line treatment for high cholesterol. Under the new framework, medications could be considered even for patients with relatively low risk, if their overall lifetime risk profile supports it.

"That's a sea change," said Dr. Steven Nissen, a preventive cardiologist at Cleveland Clinic. "A person's lifetime risk is what counts."

"These new guidelines will result in more people being treated earlier," Nissen adds. Since generic versions are available for all the major statin types, the drugs are relatively inexpensive. Nissen says he pays about $3 per month for his statin prescription.

It's estimated that 25% of adults in the U.S. have high levels of low-density lipoprotein-cholesterol, or LDL, which increases the risk of heart attacks and strokes.

Nissen says the guidelines will affect millions of people and lead to many more being treated with statins and other medicines that can lower LDL cholesterol. He stresses that an earlier and more intensive preventive approach, could lead to a significant reduction in heart attacks, strokes and cardiovascular disease, overall.

The guidelines also emphasize the benefits of modifying everyday behaviors and habits, including regular physical activity, avoiding tobacco products, and healthy sleep habits. "The cornerstone of good cardiac prevention is diet and exercise," says Leslie Cho, a preventive cardiologist at Cleveland Clinic.

The guidelines are published in the journal Circulation, and in JACC, the Journal of the American College of Cardiology.