New clinical guidelines from the American College of Cardiology, American Heart Association, and nine other leading medical associations are changing the way physicians screen and manage high cholesterol. Introduced in March, the new protocols call for monitoring dyslipidemia—abnormal levels of cholesterol, triglycerides, and other types of lipids or lipoproteins in the blood—at a younger age, in some cases in childhood. The guidelines also delve deeper into contributing factors and establish lower levels for elevated low-density lipoprotein cholesterol (LDL-C)—bad cholesterol—which increases the risk of stroke or heart attack.

“The broadening of the scope from cholesterol to dyslipidemia is a vital change,” explains Dr. Rahul Aggarwal, a fellowship-trained cardiologist at Jupiter Medical Center. “We are looking beyond traditional LDL-C and high-density lipoprotein cholesterol. The new guidelines integrate a much more comprehensive patient-centered approach to accurately combat atherosclerotic cardiovascular disease.”

Atherosclerotic cardiovascular disease is caused by the buildup of fatty deposits in the arteries and is the leading cause of death globally. The medical associations report that one in four adults has high LDL-C levels.

The new guidelines replace those from 2018 and consolidate evidence-based recommendations for managing dyslipidemia and assessing atherosclerotic cardiovascular disease risks. A major focus is earlier intervention through lifestyle changes: maintaining a healthy weight, engaging in regular physical activity, avoiding tobacco products, prioritizing healthy sleep habits, and taking cholesterol-lowering medication.

“The guidelines suggest screening children at nine to look for the one in 250 who have familial high cholesterol,” says Aggarwal. “Then we screen again between 18 and 21 and every five years.”

The new protocols also introduce a “lower is better for longer” concept, recognizing cardiovascular disease develops over decades, fueled by lifetime exposure to unhealthy lipids. By intervening earlier and keeping bad cholesterol suppressed, the medical community aims to slash the baseline rates of heart attacks and strokes.

Aggressive new target thresholds are based on a patient’s specific risk category:

While 55 mg/dL was once difficult to attain, modern therapeutics have made reaching these optimal thresholds a routine reality, notes Aggarwal. “We still use statins but have more options compared to 2018 for patients who are statin-adverse,” he says. “The non-statin alternatives achieve exceptional target numbers with minimal side effects and include oral medications and advanced injectable therapies.”

NEW EQUATIONS

Developed by the American Heart Association, the Predicting Risk of Cardiovascular Disease Events (PREVENT) calculator predicts risk at 10 years and 30 years for those 30 to 79 without known heart disease. It replaces an equation that over-predicted heart attack risks by up to 50 percent. By evaluating variables such as blood pressure, cholesterol, smoking status, blood sugar, and kidney function, it allows physicians to recognize lifetime risk trajectories in younger patients decades before a clinical event occurs.

The guidelines look beyond the standard lipid panel. Physicians are now paying attention to inflammatory markers like high-sensitivity, Creactive protein, acknowledging that inflammation plays a major role in arterial plaque formation. Additionally, the guidelines mandate a one-time adult screening for lipoprotein(a) and endorse tracking apolipoprotein B—two genetically driven proteins that carry cholesterol through the blood and act as independent predictors of heart disease.

Calcium scoring is also strongly recommended for a more complete cardiological profile. The non-invasive imaging scan detects calcium deposits in the heart’s arteries, an indicator of future heart disease. A score over 1,000 tells the physician to treat the patient aggressively.

“This is a new chapter in cardiovascular disease prevention,” says Aggarwal. “It incorporates more of the variables, besides cholesterol, that we see clinically and provides a comprehensive approach to help lower heart attacks in the future. The guidelines also embrace the idea of having a dialogue between patient and physician. It’s more collaborative.”