New cholesterol guidelines: 5 takeaways from a UChicago Medicine cardiologist who helped write them

Cardiovascular disease claims more lives in United States than any other condition, accounting for 1 in 3 deaths.

But newly updated guidelines for managing cholesterol aim to boost disease prevention and help cut heart attack and stroke rates in half.

“The vast majority of cardiovascular disease is preventable,” said Tamar Polonsky, MD, MSCI, a cardiologist at the University of Chicago Medicine.

Polonsky is a co-author of the new guidelines. Issued in March by the American Heart Association, the American College of Cardiology and nine other professional organizations, they contain changes about screenings, risk assessment and cholesterol-level benchmarks.

Polonsky shared five takeaways that patients should know:

1. Start LDL testing around age 10

Low-density lipoprotein (LDL), or “bad” cholesterol, is the primary building block of plaque in the coronary arteries that raises a person’s risk of heart disease, Polonsky said.

People might be surprised how soon monitoring can start: The new guidelines suggest having a child’s LDL levels checked at around age 10.

Screening patients at a young age can help identify those who have a genetic condition that causes very high cholesterol levels from birth. Any findings can prompt early treatment.

Adults should then begin regular LDL testing at age 19, with repeat checks at least every five years — or more often if their numbers are high.

“Even people in their twenties can start to develop plaque,” Polonsky said.

2. High-risk people need lower LDL levels than before

The new guidelines, backed by more clinical evidence, advise high-risk individuals to target a lower LDL: 55 mg/dL or below. (The last guidelines, published in 2018, recommended an LDL below 70 mg/dL for this group.)

High-risk individuals are those who have had a heart attack or stroke and have multiple additional risk factors, such as diabetes, hypertension or smoking. It also includes people who have had more than one heart attack or stroke.

Most people should aim for LDL below 100 mg/dL. About 1 in 4 people have a level of 130 mg/dL or higher, putting their cardiovascular risk at the “borderline high” mark.

Still, taking steps to lower LDL levels can benefit anyone.

“There really is no LDL that’s too low when we’re trying to lower a person’s cardiovascular risk,” Polonsky said.

3. Get tested for an inherited biomarker called lipoprotein(a)

The guidelines recommend all adults get a one-time blood test to measure lipoprotein(a) — or Lp(a) — a cholesterol-carrying particle found in the blood.

This test is especially important if you have a first-degree relative with elevated Lp(a).

An Lp(a) level above 125 nmol/L indicates higher cardiovascular risk. High Lp(a) levels increase heart risk by promoting inflammation and can lead to clots in the coronary arteries, causing a heart attack.

Unlike LDL, you can’t change Lp(a) with diet or exercise.

If elevated Lp(a) is detected, a person should have a thorough evaluation of their cardiovascular risk factors — including blood pressure, glucose and lifestyle. Depending on the Lp(a) level and other risk factors, cholesterol-lowering medication may be needed.

Statins don’t lower Lp(a), but they are still the primary treatment for people with high Lp(a) because they lower LDL and decrease inflammation — two primary drivers of plaque buildup.

“There’s been so much more data about the association of Lp(a) with cardiovascular risk” since the previous guidelines, Polonsky said. “There are drugs that have been developed specifically to lower Lp(a) and are being studied in clinical trials to determine whether they also lower the risk of heart attack or stroke.”

4. Take a longer-term view of cardiovascular risk

The longer you live with high LDL levels, the greater your risk for heart disease.

That’s why the new guidelines advise calculating a person’s risk for cardiovascular disease over the next 30 years.

“There are so many other things in our lives, like our education and retirement, where we take a long view and make long-term investments,” Polonsky said. “We need to do the same with our cholesterol.”

The guidelines recommend a new, robust risk assessment calculator called PREVENT that can forecast a patient’s 10- and 30-year risk of heart disease, informing medication decisions. A person’s PREVENT score should be measured as early as age 30, and it is based on easily measured factors, such as age, blood pressure, cholesterol and kidney function.

The PREVENT calculator offers an improvement over prior risk calculators because it more accurately estimates a person’s risk of a heart attack or stroke.

“The guidelines are not about just putting more people on medicine,” Polonsky said. “They’re about trying to better identify who will benefit the most from medication.”

5. Maintain healthy habits, but don’t rule out medication

Good habits matter for heart health. “Healthy diet and exercise are always the foundation of cardiovascular disease prevention,” Polonsky said.

Those steps may be enough for some people to lower their LDL levels, but many at-risk people also need medication.

Statins, which are drugs designed to lower LDL, work well for most individuals, but not everyone, Polonsky said. A growing number of medications can work for people who either cannot tolerate statins or get their LDL low enough with statins alone.

Supplements are not proven to lower LDL.

“I recognize that some people want to use vitamins and other supplements for their overall health, but I want to make it very clear that these supplements are not an effective way to lower LDL,” Polonsky said.