New heart health recommendations emphasize early testing and treatments to lower cholesterol levels as key to reducing the risk of cardiovascular disease.
A group of 11 medical associations, including the American College of Cardiology and the American Heart Association released new guidelines on March 13 to help doctors and their patients manage their cholesterol levels. Recommendations advise testing cholesterol levels first in childhood, around age 10, with the goal of helping patients maintain low levels, thereby reducing the risk of heart attack or stroke in coming decades. Also new is a cardiovascular risk calculator called PREVENT, designed to assess the risk of heart attack and stroke over the next 10 and 30 years in adults ages 30 to 79 who do not already have heart disease.
Previous recommendations, published in 2018, relied on another calculator based on clinical data from a cohort of about 25,000 adults who participated in studies sponsored by the U.S. National Institutes of Health, says Roger Blumenthal, a cardiologist at the Johns Hopkins School of Medicine. This calculator only hoped for 10 years. Additionally, the guidelines did not provide specific cholesterol benchmarks for people with different levels of risk based on family or medical history.
PREVENT, for its part, is based on studies covering a total of 6.6 million people, making it possible to better estimate short- and long-term risks on an individual basis, explains Blumenthal. The new guidelines also emphasize additional tests that are not part of the standard cholesterol blood test or lipid panel, including a unique assessment of lipoprotein(a) or Lp(a). Lp(a) levels are determined by genetics and may increase the long-term risk of heart attack or stroke.
About a quarter of American adults have high levels of low-density lipoprotein cholesterol, or LDL. Reducing these “bad” cholesterol levels through lifestyle changes such as healthy eating and exercise or with medication can reduce the risk of cardiovascular disease, the leading cause of death worldwide.
Scientific news spoke with Blumenthal, who chaired the guideline writing committee, to learn more about the new recommendations and how the changes could impact treatment. This conversation has been edited for length and clarity.
SN: What are the most important changes in the guidelines?
Blumenthal: I’ll start with number one, which is basically assess and treat early. We have recommended – especially if there is a family history of heart disease or if there is another cardiovascular risk factor – that the clinician screen with a lipid panel around age 10, then again around age 20, and then every five years thereafter.
We also pointed out that, especially if you are 30 and older and your LDL cholesterol level is 160 or higher on many occasions, it certainly makes sense to consider starting a cholesterol-lowering medication if there is a family history of heart disease or other risk factors.
We now have a more robust and accurate risk estimator that we call PREVENT. I think one of the best things about PREVENT is that we have a good way to estimate long-term risk. We can say [patients with certain risk factors] that even though their risk over the next 10 years is very low, their risk over the next 20 to 30 years is quite high.
If there is a family history of cardiovascular disease, even if your estimated risk in your 30s is quite low, clinicians should talk to their patients about it. [healthy lifestyle habits]. Many young adults in their 30s and 40s are at very low risk at age 10 because much of the PREVENT score is based on chronological age rather than biological age. But we can now estimate the risk over 30 years. If you have a person in front of you who is told the [10-year] the risk is one, two or three percent, but [the calculator can] tell them that if you don’t change your lifestyle habitsif you don’t improve your weight, your cholesterol, your blood pressure, your risk at age 30 could very well be 30 percent, that gets their attention.
Reduce cholesterol
A new cardiovascular risk calculator called PREVENT is designed to assess the risk of heart attacks and strokes over the next 10 or 30 years. New cholesterol guidelines emphasize early treatment of people at lower levels, with cardiovascular disease risk divided into four categories: low, borderline, intermediate and high. People at low 10-year risk (less than 3%) should focus on changing their lifestyle. People at borderline (3 to 5%) or intermediate (5 to 10%) risk can or should consider starting treatment to lower LDL levels. High-risk patients (10% or more) should consider taking medications to lower their LDL cholesterol levels to less than 70 milligrams per deciliter and making lifestyle changes.
SN: What are the most important criteria people should know?
Blumenthal: The key numbers to remember are LDLs of 100, 70, and 55. We say that in all individuals at borderline risk – and in fact I would say for all adults – we like them to strive to improve their lifestyle habits so that they can reduce their LDL to 100 milligrams per deciliter or less. We know that people who may have signs of mild to moderate atherosclerotic disease or who have multiple risk factors may want to try to lower their LDL levels to the 70 mg/dL range. [For high-risk individuals] we have good data that it’s best to get their LDL closer to the 55 mg/dL range.
A single measurement of lipoprotein(a) may be a useful way to decide [for risk assessment, even if other lipid levels are normal]. We have put in place the guidelines that if your Lp(a) is [above a certain threshold] that your risk is probably twice as high as that estimated by the PREVENT score.
We also noted that there are some high-risk groups that clinicians need to remember: those with diabetes, chronic kidney disease, or HIV infection. We have very good data that if their LDL levels are suboptimal, statin therapy in addition to more aggressive lifestyle changes makes a lot of sense.
SN: Why did you and the committee decide to make these changes?
Blumenthal: First, we have a more accurate risk calculator. Second, we wanted to follow the same logic that the American Heart Association and the American College of Cardiology followed with the recent blood pressure guidelines. They said that if, even after six months of trying to improve your lifestyle, your blood pressure remains above 130/80, you should seriously consider taking medication. We felt that with this same proactive approach, that if a person is 30 and older and has consistently higher LDL cholesterol levels, that [considering medication] makes sense.
SN: Is this why the emphasis is on early treatment??
Blumenthal: It’s really important to start giving health behavior advice to young people. Pediatricians generally have a strong philosophy when it comes to prevention. My late father was a pediatrician. I think much of my interest in preventive cardiology came from my discussions with him about [how] The habits that one develops in youth or adolescence are generally the habits that [one] will follow later.
