What’s Different About the New Cholesterol Guidelines?

Cardiovascular disease remains a leading health concern in the United States, and it is becoming more common among younger people.

In response, the American College of Cardiology, the American Heart Association, and nine other leading medical associations recently developed new guidelines for managing your cholesterol.

The new guidelines recommend earlier testing and treatment, assessing risk more broadly, and achieving specific LDL levels—levels of the “bad cholesterol” known as low-density lipoprotein cholesterol.

In this Q&A, Robert S. Rosenson, MD, the Dr. Rony Shimony Distinguished Professor of Cardiovascular Medicine at the Icahn School of Medicine at Mount Sinai, explains some of the most significant changes.

“The more information your doctor has about your heart health, the easier it is to develop the best treatment for you,” says Dr. Rosenson, who is also Director of Metabolism and Lipids for the Mount Sinai Health System.

Why are the new guidelines important?

The last set of guidelines came out eight years ago. Since then, there have been major shifts in our society and advances in scientific research. These guidelines take into account these changes and align with recent European standards. They will help keep Americans healthier. But the guidelines can only keep you healthier if you follow them. It is important to get your cholesterol tested regularly and make sure the levels are in a healthy range. If they are not, talk with your health care provider about ways to lower your LDL.

What are the biggest changes to the guidelines?

One of the biggest changes is focusing on the LDL level. Earlier guidelines focused on how much cholesterol medicine patients were taking. The new guidelines emphasize the actual LDL level for people with different levels of risk for cardiovascular disease. For example, if your risk of heart disease is higher, you should aim for a lower LDL level.

The recommended LDL levels are:

For those with a low risk of heart disease: 100 mg/dL (milligrams per deciliter, which is a measure of cholesterol in your blood)

For those with a medium risk: 70 mg/dL or lower. Moderate risk includes people who have:

• Calcium buildup in the arteries.
• A high-risk condition such as diabetes or high blood pressure.
• Family history of heart disease.

For those with a high risk of heart disease: 55 mg/dL or less. This includes people who have:

• Already had a heart attack or stroke.
• Two or more serious risk factors, such as diabetes and heart disease.
• Imaging evidence of coronary artery disease based on a coronary calcium score of 300 or higher or age-adjusted coronary calcium at the 75th percentile.

How do the new guidelines assess cardiovascular risk?

The new guidelines take a broader view of heart disease risk than earlier guidelines. They still check bloodwork such as a lipid panel. But they also review family history of heart disease, history of smoking, and body mass index (BMI). The guidelines consider whether you have conditions such as diabetes, chronic kidney disease, or are overweight or obese. And they look at more markers of atherosclerotic cardiovascular risk in your blood. These include:

• lipoprotein(a)
• apolipoprotein B
• high-sensitivity C-reactive protein
• elevated triglycerides

Thus, the guidelines officially changed from a cholesterol guideline to a dyslipidemia guideline, which covers cholesterol as well as other lipids (fats) in your blood.

Looking at all these factors gives us a clearer picture of your personal risk of heart disease. HDL, the so-called “good cholesterol,” also may not be as good as a marker of protection as once thought. For instance, if you have insulin resistance, prediabetes, or diabetes, your LDL cholesterol particles are probably smaller and denser. This means LDL cholesterol may not tell the whole story of your heart disease risk. Instead, the guidelines recommend focusing on these markers. This includes non-HDL cholesterol or the difference between total cholesterol and HDL cholesterol and apolipoprotein B (the major structural protein on the “bad” particles”). They also recommend having a coronary calcium scan because those results can also affect your risk level.

Do the new guidelines start at a younger age?

The new guidelines recommend getting a full lipid profile for children ages 9 to 11. For children who have high LDL cholesterol because of a family history (including a lipid disorder known as hypercholesterolemia), the guidelines suggest screening starting as early as age two. In rare cases, children with this condition have had heart problems even as toddlers. The guidelines recommend getting a one-time check of lipoprotein(a) levels. This is often related to genetic risk. High LDL cholesterol affects your heart risk throughout your life, so the earlier you start keeping low LDL cholesterol levels, the better.

Do the new guidelines discuss treatment options?

Many people take supplements, like fish oil, to improve their heart health. The new guidelines say there is no scientific evidence that supplements can help lower cholesterol or decrease the risk of heart disease. Talk to your doctor about the best approach to improving your heart health.