80% or more of cardiovascular disease is preventable and elevated LDL cholesterol, sometimes referred to as ‘bad’ cholesterol, is a major part of that risk.
Photo Credit: istockphoto
A major focus of the guideline is 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 when recommended by a health care professional.
The American College of Cardiology (ACC) along with the American Heart Association and nine other leading medical associations released an updated guideline for the management of dyslipidemia—abnormal levels of one or more types of lipids or lipoproteins in the blood, including cholesterol and triglycerides.
The guideline consolidates evidence-based recommendations for managing dyslipidemias into one document, offering a comprehensive “one-stop shop” for how to best assess and treat various blood lipids to effectively lower an individual’s risk of developing atherosclerotic cardiovascular disease (ASCVD). ASCVD is caused by buildup of fatty deposits in the arteries and is the leading cause of death globally, according to a report featured in heart.org. 1
A major focus of the guideline is 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 when recommended by a health care professional. In addition, the guideline reinforces lower LDL-C goals and percent reduction based on risk to reduce lifetime exposure to unhealthy lipids and the risk of heart attack and stroke.
Dr. Roger Blumenthal, chair of the guideline writing committee and director of the Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease in Baltimore said, “We know 80% or more of cardiovascular disease is preventable and elevated LDL cholesterol, sometimes referred to as ‘bad’ cholesterol, is a major part of that risk.”
“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, added Dr. Roger Blumenthal.
The earlier risk scores like the Pooled Cohort Equations overestimated the 10-year risk of a heart attack and stroke by nearly 40% to 50%. The latest guideline moves from the old pooled cohort equations to the AHA PREVENT-ASCVD risk calculator for prevention decisions. This tool measures 10- and 30-year risks of atherosclerotic cardiovascular disease (ASCVD). They have been categorized below as:
Less than 3%: Low
3-5%: Borderline
5-10%: Intermediate
10% or higher: High
The aforementioned risk categories guide treatment related decisions that will include whether to begin statin therapy and the recommended intensity of lipid-lowering therapy.
“With this new assessment tool, we can better estimate cardiovascular risk using health information already obtained during an annual physical—cholesterol, blood pressure readings and other personal information such as age and health habits—and then further personalize the risk score for each individual by looking at ‘risk enhancers,’ which can help guide the need for lipid-lowering therapy,” Blumenthal added.
The latest guideline recommends the consideration of additional tests, when appropriate, to improve cardiovascular risk assessment and assess if more intensified LDL-C lowering and management of other risk factors is needed. These include:
Selective use of a non-contrast coronary artery calcium (CAC) scan. This can be used to check for early or subclinical calcium and plaque buildup in the walls of the heart’s arteries when there remains uncertainty about a person’s true risk. It is recommended for men age 40 and older and women age 45 and older with borderline or intermediate 10-year risk of heart attack or stroke if knowing CAC will help with the decision to prescribe a statin or not. Having any amount of coronary artery calcium supports an LDL-C goal of less than 100 mg/dL—with lower LDL-C target levels with higher amounts of calcium, added the heart.org report.
Lipoprotein (a). Lp(a) should be measured at least once in adulthood. Lipoprotein (a), or Lp(a), is a genetically inherited type of LDL ("bad") cholesterol particle that carries cholesterol through the bloodstream. Lp(a) levels are largely genetically determined and remain relatively stable over a lifetime. High Lp(a) (125 nmol/L or greater or 50 mg/dL or greater) is associated with about a 1.4-fold increased long-term risk of heart attack or stroke. An Lp(a) of 250 nmol/L is associated with at least a two-fold increased long-term risk of heart attack or stroke. Lifestyle changes minimally affect Lp(a) levels, so repeat testing is generally not needed.
Apolipoprotein B. Measuring apoB may be used to assess any residual ASCVD (Atherosclerotic Cardiovascular Disease) risk and guide treatment among people with cardiovascular-kidney-metabolic syndrome, Type 2 diabetes, high triglycerides or known cardiovascular disease who have reached their LDL-C and non-HDL-C goals. ApoB may be a more accurate risk marker than LDL-C in these groups of people.
LDL-C cholesterol and non-HDL-C goals are back in the new guideline. Non-HDL-C is total cholesterol minus HDL (good) cholesterol. To prevent a first heart attack or stroke, the LDL-C goal should be less than 100 mg/dL for those at borderline or intermediate risk and less than 70 mg/dL in those at high risk. For individuals with ASCVD who are at very high risk of ASCVD events, the LDL-C goal should be less than 55 mg/dL for secondary prevention of cardiac events, emphasised the heart.org report.
The guideline also outlines treatment for hypertriglyceridemia—abnormally high levels of triglycerides. Lifestyle changes and statin therapy remain the mainstay of treatment here as well due to the increased risk of ASCVD. However, other therapies may be needed based on an individual’s ASCVD and pancreatitis risk.
In addition, the guideline 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. Cholesterol screening is recommended for all children between the ages of 9-11 years not previously screened to help assess risk and guide care, in collaboration with clinicians, parents and caregivers, as per the heart.org report.
How do the new ACC/AHA guidelines differ from previous dyslipidemia management recommendations?
The updated guideline introduces the AHA PREVENT-ASCVD risk calculator, replacing the older pooled cohort equations to better estimate 10- and 30-year cardiovascular risk. It emphasizes earlier intervention with lifestyle changes and earlier initiation of lipid-lowering medications. Additionally, it lowers LDL-C goals based on risk categories and recommends selective testing like coronary artery calcium scans and lipoprotein(a) measurements to personalize treatment.
What role do lifestyle changes play in managing dyslipidemia according to the new guideline?
Lifestyle modifications are the foundational step in dyslipidemia management. The guideline highlights maintaining a healthy weight, regular physical activity, avoiding tobacco, prioritizing sleep, and a heart-healthy diet to reduce LDL cholesterol and overall ASCVD risk. If lipid levels remain elevated despite lifestyle optimization, earlier consideration of cholesterol-lowering medications is advised.
When is statin therapy recommended based on the new risk assessment categories?
Statin therapy recommendation depends on the individual's 10-year ASCVD risk calculated by the AHA PREVENT-ASCVD tool. Those with borderline (3-5%) or intermediate (5-10%) risk may consider statins if risk enhancers or test results like CAC scores justify it. High-risk individuals (≥10%) are generally recommended statins, with intensity guided by LDL-C goals to reduce heart attack and stroke risk.
What is the significance of measuring lipoprotein(a) and apolipoprotein B in cardiovascular risk assessment?
Lipoprotein(a) measurement is recommended at least once in adulthood as elevated levels (≥125 nmol/L or 50 mg/dL) increase long-term risk of heart attack or stroke. Apolipoprotein B measurement helps assess residual ASCVD risk, especially in people with diabetes, high triglycerides, or established cardiovascular disease who have achieved LDL-C goals. Both markers refine risk stratification beyond traditional lipid tests.
Why is cholesterol screening recommended for children and adolescents?
High cholesterol can affect cardiovascular risk starting in childhood due to genetics or lifestyle. Screening all children between ages 9-11 helps identify those at elevated risk, enabling early intervention with lifestyle changes or medical treatment to prevent future ASCVD. Collaboration among clinicians, parents, and caregivers is essential for effective management.
Disclaimer: This content is for general informational purposes only and should not replace professional medical advice. Always consult a qualified healthcare provider with any questions about your health or treatment options.
At marvelof.com, we spotlight the latest trends and products to keep you informed and inspired. Our coverage is editorial, not an endorsement to purchase. If you choose to shop through links in this article, whether on Amazon, Flipkart, or Myntra, marvelof.com may earn a small commission at no extra cost to you.