New clinical guidelines from the American College of Cardiology (ACC) and the American Heart Association (AHA) are placing a greater emphasis on early detection, personalized risk assessment, and more aggressive lowering of low-density lipoprotein (LDL) cholesterol to reduce the long-term risk of cardiovascular disease.
Cardiovascular disease remains the leading cause of death globally, and millions of adults have cholesterol levels that place them at increased risk. The updated recommendations, published jointly in the Journal of the American College of Cardiology and Circulation, aim to address this by focusing on LDL cholesterol, often called “bad” cholesterol, and other blood lipids like lipoprotein(a) (Lp(a)).
Earlier Screening and Broader Risk Factors
The guidelines call for earlier cholesterol screening, particularly for individuals with a family history of cardiovascular disease. Clinicians are encouraged to consider a wider range of health factors when evaluating a patient’s long-term risk and treatment options. Roger S. Blumenthal, M.D., chair of the guideline writing committee and director of the Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, stated that lower LDL cholesterol levels are better for reducing the risk of heart attacks, strokes, and congestive heart failure. He also noted the importance of addressing elevated lipids and blood pressure in young adults for lifelong cardiovascular health.
Approximately one in four U.S. adults has elevated LDL cholesterol, a key contributor to atherosclerosis, the narrowing or hardening of arteries. This condition can lead to restricted blood flow and potentially result in heart attacks or strokes.
A significant update includes recommendations for earlier screening, especially for those with a family history of atherosclerosis. The guidelines also highlight the importance of considering factors such as rheumatoid arthritis, early menopause, preeclampsia, and gestational diabetes in risk evaluations. Individuals with familial hypercholesterolemia, an inherited condition causing very high LDL-C levels, are now advised to begin screening around age 9 or earlier. The guidelines also recommend a one-time test for Lp(a), a genetically influenced factor associated with increased heart disease risk at certain levels.
New Risk Assessment Tool and Treatment Strategies
A major change is the adoption of the PREVENT Risk Calculator, a new tool for estimating both 10-year and 30-year risks of heart attack and stroke. Unlike the previous calculator, which focused on adults aged 40 and older and used factors like age, cholesterol, and blood pressure, PREVENT is recommended for use starting at age 30 and incorporates additional measures such as blood sugar and kidney health indicators. The PREVENT calculator was developed using data from 6.6 million people, significantly more than the approximately 26,000 used for the earlier tool.
“Shifting the paradigm toward proactive prevention strategies earlier in life can meaningfully change the trajectory of cardiovascular disease and lead to better health outcomes for people decades later,” said Seth Martin, M.D., M.H.S., a member of the guideline writing committee and director of the Advanced Lipid Disorders Program and Digital Health Lab at the Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease.
To further personalize risk evaluation, the guidelines suggest considering “risk enhancers,” which may include high-sensitivity C-reactive protein (hsCRP), elevated Lp(a), a family history of early cardiovascular disease, and higher-risk ancestry. Coronary artery calcium scans are also recommended for some individuals to help tailor treatment plans.
The document also provides guidance for specific populations, including pregnant or lactating women, adults over 75, and individuals with conditions like diabetes, advanced chronic kidney disease, HIV infection, or cancer. Updated recommendations cover the use of statins and other cholesterol-lowering therapies, such as ezetimibe, bempedoic acid, and injectable PCSK9 monoclonal antibodies, for those who do not achieve sufficient LDL-C reduction with statins alone or require combination therapy.
For individuals without cardiovascular disease, optimal LDL-C levels are recommended to be below 100 mg/dL. The guideline suggests lowering LDL-C to below 70 mg/dL for those at intermediate risk and below 55 mg/dL for individuals at higher risk. Targets and recommendations for non-HDL-C and apolipoprotein B are also included.
Steve Lopez is the Editorial Page Editor for News Raise. He covers Health. He has won more than a dozen national journalism awards for his reporting and column writing at seven newspapers and four news magazines.
