Updated guideline recommends earlier intervention to prevent cholesterol disease

Eleven medical organizations, including the American College of Cardiology (ACC) and the American Heart Association, have issued an updated guideline for managing patients with dyslipidemia, which is abnormal levels of cholesterol and triglycerides.

The guideline, published in the Journal of the American College of Cardiology and Circulation, uses a newer cardiovascular disease risk calculator to evaluate patients beginning at age 30 for factors that could lead to heart disease. The new scale, the Predicting Risk of Cardiovascular Disease EVENTs (PREVENT), allows doctors to consider lifetime risk and takes into account lifestyle changes and medication when appropriate.

The goal of the new guideline is to prevent cardiovascular disease by addressing risk at a younger age. The guideline lists treatment targets for low-density lipoprotein cholesterol (LDL-C), the “bad cholesterol” that can increase the risk of heart attack and stroke. The guidance notes that high cholesterol can begin to impact heart disease risk even in childhood and adolescence. Children may have high cholesterol due to inherited conditions or lifestyle habits.

“This guidance reflects a fundamental shift in how we think about cholesterol—not just as a short‑term number, but as a lifelong exposure that shapes cardiovascular risk. By intervening sooner and using better risk assessment tools, we have a real opportunity to prevent disease rather than simply treating it after the fact,” Anand Rohatgi, M.D., said in a news release. He is a professor of internal medicine in the Division of Cardiology at UT Southwestern Medical Center.

Approximately 1 in 4 U.S. adults has high levels of low-density lipoprotein-cholesterol (LDL-C), which increases the risk of heart attack and stroke.

The new recommendation is that LDL-C should be less than 100 mg/dL for people without risk factors. For those at risk for heart disease, including those with diabetes or an elevated 10-year risk, the LDL-C goal is below 70 mg/dL. For those who have already had a heart attack or stroke and are at highest risk of cardiovascular events, the LDL-C goal is below 55 mg/dL.

The new guidance also expands the role of testing. Coronary artery calcium (CAC) scoring is recommended for borderline or intermediate risk adults who are uncertain about whether to start cholesterol medicine. CAC testing uses a CT scan to identify evidence of cholesterol buildup in the arteries. If any CAC is present, statins are recommended.

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The guideline also recommends all adults have a lipoprotein(a) [Lp(a)] test at least once in their lifetime. Lp(a) is a type of cholesterol that increases the risk of heart disease but is not detected by traditional cholesterol tests. High levels of lipoprotein(a) are a risk factor for cardiovascular disease and can lead to plaque buildup and narrowing of the arteries, inflammation and blood clots. This fat, which is similar in structure to LDL, can cause plaque buildup and narrowing of the arteries, inflammation and blood clots.

The guideline focuses on earlier intervention through healthy lifestyle changes, such as maintaining a healthy weight, engaging in regular physical activity, avoiding tobacco products, prioritizing healthy sleep habits and taking cholesterol-lowering medication.

“While we want to try to optimize healthy lifestyle habits as the first step to lower cholesterol, we realize that if lipid numbers aren’t within the desirable range after a period of lifestyle optimization, we should consider adding lipid-lowering medication earlier than we would have considered 10 years ago. And lower LDL cholesterol for longer, just like lower blood pressure for longer, results in much greater protection against future heart attack and stroke risk,” Roger Blumenthal, M.D., FACC, FAHA, chair of the guideline writing committee, said in a news release. He is director of the Johns Hopkins Ciccarone Center for the Prevention of Heart Disease and the Kenneth J. Pollin Professor of Cardiology at Johns Hopkins Hospital in Baltimore.