New national cholesterol guidelines are changing how doctors assess and treat heart disease risk, with a stronger focus on earlier screening, lifetime prevention and more individualized care.
The updates — issued jointly by 13 medical societies — are the first major revisions since 2018. They encourage clinicians to look beyond short-term risk and identify patients who may benefit from treatment decades before symptoms appear.
“We like to prevent disease,” said Dr. Jonathan Katz, a cardiologist with Crystal Run Healthcare. “We don’t like to treat disease after.”
Katz said one of the biggest changes is a shift toward treating patients to specific cholesterol targets instead of simply prescribing medication and monitoring percentage reductions.
The new recommendations also rely on an updated risk assessment tool called the PREVENT calculator, which analyzes data from millions of patients and includes factors not used in older models.
“The current guidelines, they wanted to change the way that we calculate risk using a more up-to-date risk calculator,” Katz said.
Unlike earlier tools, the PREVENT calculator can incorporate kidney disease, blood sugar levels and other health indicators to better estimate both 10-year and 30-year cardiovascular risk.
“That helps to determine if patients should be just using lifestyle modifications or lipid-lowering therapies, such as statins or other newer lipid-lowering therapies,” Katz said.
Earlier screening, especially for families with heart disease
The guidelines place greater emphasis on screening younger patients, especially those with a family history of cardiovascular disease.
“If there’s a family history of heart disease, it’s critical for patients to get screened early,” Katz said. “Even if there’s a heavy family history, even at age 2.”
For children without severe risk factors, screening is recommended between ages 9 and 11. Adults should generally begin cholesterol testing around age 20 and repeat it every five years, Katz said.
He noted that prevention can make a major difference.
“About 80% of heart disease and stroke and vascular disease is preventable if we are able to treat all the risk factors,” he said.
New focus on lipoprotein(a)
The guidelines also recommend broader testing for lipoprotein(a), often called Lp(a), a genetic risk factor linked to early cardiovascular disease.
“Some patients will have their cholesterol checked and it will be normal,” Katz said. “But if you check the lipoprotein A, that is a dangerous particle that travels around the blood and it can cause buildup of plaque.”
Elevated Lp(a) levels can signal inherited risk and may help explain why some patients develop heart disease at unusually young ages.
“If lipoprotein A is elevated, that indicates that there might be a familial risk and the patient should be treated aggressively because they could develop heart disease 20 years earlier than other patients,” Katz said.
Lifestyle changes still the first step
While the guidelines support earlier intervention, Katz stressed that diet, exercise and other lifestyle changes remain central to prevention.
“We always start with diet,” he said, including lowering saturated fats, increasing fiber and exercising regularly.
Doctors may consider medication if lifestyle changes do not lower cholesterol enough or if a patient’s overall risk remains elevated.
The updated recommendations also encourage more personalized treatment decisions, taking into account conditions such as diabetes, kidney disease, autoimmune disorders and premature menopause.
In some borderline cases, Katz said doctors may recommend a cardiac CT scan to measure calcium buildup in the arteries and refine a patient’s risk profile.
Beyond statins
Statins remain the standard treatment for lowering LDL, or “bad,” cholesterol. But the guidelines also discuss newer therapies for patients who cannot tolerate statins or need additional cholesterol reduction.
Katz pointed to PCSK9 inhibitors — injectable medications taken every two weeks — as an increasingly important option.
“It’s an amazing modern creation,” he said. “It helps lower LDL dramatically and it helps lower risk and it’s very well tolerated by patients.”
A largely silent condition
High cholesterol often has no symptoms until serious disease develops, making routine screening especially important, Katz said.
“Once symptoms arise, then it’s usually more advanced,” he said.
Possible warning signs of cardiovascular disease can include chest pain, shortness of breath, dizziness, palpitations or swelling in the legs.
Still, Katz said the larger goal is prevention before symptoms begin.
“Everyone should know what their cholesterol is,” he said. “Go see your doctor, talk about the cholesterol numbers that you have, talk about the new guidelines.”