The new American guidelines for managing blood lipids seek to change one of the fundamental concepts in preventive medicine: Not to wait until old age or until cardiac risk is clearly defined, but to begin assessing it earlier, sometimes already in the 30s. The new guidelines were published jointly by the American Heart Association, the American College of Cardiology and additional medical organizations, and they replace the 2018 document.
The new document deals with dyslipidemia, meaning abnormal levels of fats in the blood such as cholesterol and triglycerides. According to the American Heart Association, one in four adults in the United States suffers from high levels of LDL, the "bad" cholesterol, which is considered a major risk factor for heart attack and stroke.
Cholesterol tests from age 19
One of the main innovations is the emphasis on earlier prevention. According to the guidelines, blood lipid screening should begin in adults from age 19, and in people aged 30 to 79 without known heart disease, a new risk calculator called PREVENT should be used (to enter the calculator - click here), which estimates not only a 10-year risk but also a longer-term cumulative risk. The calculator combines data such as BMI, cholesterol levels, smoking and additional factors.
This is an important change, because the new approach emphasizes that atherosclerotic disease is a lifelong process. Instead of asking only what a person’s risk is in the next decade, the recommendation is to also examine the cumulative cost of many years with high LDL. According to Professor Roger Blumenthal, chair of the guideline writing committee, the goal is to help doctors and patients understand when lifestyle changes are enough, and when earlier drug treatment should be considered.
In the updated guidelines, the 10-year risk categories in the PREVENT calculator were redefined: Low risk is less than 3 percent, borderline is 3 to less than 5 percent, moderate is 5 to less than 10 percent, and high is 10 percent and above. According to experts, this change is expected to lead to a more accurate assessment of relatively young patients, especially if they smoke, suffer from high blood pressure, high blood sugar, type 2 diabetes or a family history of heart disease.
Statins from age 30
Another innovation is a clearer recommendation to consider statin treatment already from age 30 in adults with LDL of 160 mg per deciliter or higher. In addition, the document emphasizes that drug treatment should not be ruled out only because the 10-year risk does not seem "dramatic", if the lifetime cumulative risk is high. In other words, even a person with borderline short-term risk may be a candidate for treatment if an overall picture of long-term risk accumulates.
For the first time in years, the guidelines also bring back clear LDL targets:
• For most people without significant risk factors, the target is below 100 mg per deciliter
• In high-risk individuals the target drops to below 70
• In patients who already have cardiovascular disease and are at very high risk, the strict target is below 55
According to the document, lower LDL levels have been linked to fewer heart attacks and strokes in at-risk populations.
But perhaps the most intriguing innovation is not only the starting age, but also the new tests entering the picture. The guidelines now recommend considering the apoB test, a protein that sits on the surface of harmful lipoproteins such as LDL. In people with high triglycerides, type 2 diabetes or cardio-renal-metabolic syndrome, apoB may provide a more accurate picture of residual risk even when LDL already appears "controlled" on paper.
At the same time, for the first time there is a recommendation that every person undergo at least once in their lifetime a Lipoprotein(a) test, or Lp(a). This is a type of cholesterol that is mostly genetically determined and is not detected in routine cholesterol tests. High levels of it have been linked to a very increased risk of fat buildup in arteries. According to the guidelines, a value above 250 nanomoles per liter is associated with roughly a doubling of heart disease risk, and a value above 430 is associated with an even sharper increase. Even though there is still no routine targeted treatment available that lowers Lp(a), the test can change the overall risk assessment and lead to a more aggressive approach to treating other risk factors.
Not waiting until age 55
Another tool that is being more strongly emphasized in the recommendations is the coronary artery calcium test. According to the document, in men aged 40 and over and women aged 45 and over who are at borderline or moderate 10-year risk, a CAC scan may be considered to detect early calcification in the heart arteries and refine treatment decisions. The presence of calcium in the arteries supports a more active approach to lowering LDL.
Despite all the technological and laboratory innovations, the guidelines emphasize that the basics have not changed. The main causes of heart disease remain the same traditional factors: High cholesterol, high blood pressure, diabetes, smoking, obesity and lack of physical activity. The American Heart Association continues to emphasize that a healthy diet, regular physical activity, good sleep and smoking cessation are the first line of defense. It is estimated that about 80 percent of heart disease and stroke cases can be prevented through a healthy lifestyle.
The bottom line of the new guidelines is simple but significant: If waiting until age 55 or 60, sometimes part of the damage has already been built into the arteries. The updated approach aims to identify risk earlier, think about entire lifetimes rather than just the next decade, and tailor more precise treatment to each individual. For cardiologists, this is not a complete revolution, but an evolution toward smarter prevention.