It's estimated that about one in four adults in the US has high LDL cholesterol, which can build up in your arteries over time, increasing the risk of heart attack and stroke.
But 'bad' cholesterol isn't the only thing you need to look out for.
Other kinds of lipids and lipoproteins can also build up in your blood to abnormal levels, called dyslipidemia, which in turn can lead to atherosclerotic cardiovascular disease (ASCVD), the world's leading cause of death and morbidity.
This year, experts in the US updated their official guidance on how to manage cholesterol and prevent dyslipidemia, overhauling the former 2018 guidelines.
The new guidelines are still very much about managing cholesterol, but they also take a broader perspective, focusing on taking action earlier to address blood fats that can harm people's health.
"We know 80 percent or more of cardiovascular disease is preventable and elevated LDL cholesterol, sometimes referred to as 'bad' cholesterol, is a major part of that risk," says cardiologist Roger Blumenthal from the Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, the chair of the guideline writing committee.
"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."
In the new guidelines, written for doctors and clinicians, the main focus is to begin treating dyslipidemia earlier to reduce the lifelong risk associated with prolonged exposure to atherogenic lipoproteins.
"Lower LDL cholesterol for longer, just like lower blood pressure for longer, results in much greater protection against future heart attack and stroke risk," Blumenthal says.
This means cholesterol screening is recommended to begin in children aged 9–11 years, if they haven't been screened previously, although it can begin as young as two years of age if there's a family history of serious cardiovascular or cholesterol-related disease.
Another change is that doctors are advised to use a new disease-risk calculator, called PREVENT, to estimate 10-year and 30-year cardiovascular disease risk in patients aged 30 to 79.
"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 says.
Depending on the calculations of the new equations, doctors can consider LDL-lowering therapies – including lifestyle interventions, but also LDL-lowering drugs, such as statins – if patients are deemed borderline risk (3–5 percent chance) of developing ASCVD in 10 years, and ought to consider it in intermediate risk cases (5–10 percent risk).
The new guidelines also reintroduce new goal levels for LDLs to guide lipid-lowering therapy, with the researchers saying LDL-C goals should be less than 100 mg/dL for those at borderline or intermediate risk, and less than 70 mg/dL for those at high risk. In patients with ASCVD deemed very high risk, the target is less than 55 mg/dL.
"In general, lower LDL is better, especially for people at increased risk for a heart attack or stroke," says cardiologist Pamela B. Morris from the Medical University of South Carolina.
" Clinical trials have clearly demonstrated significant benefits for reduction in cardiovascular events when LDL-C levels are even lower than recommended in previous guidelines."
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While statins are the primary medications used to lower LDL levels, the guidelines also incorporate other drugs, including ezetimibe, bempedoic acid, PCSK9 inhibitors, and inclisiran.
For patients, the updated advice is to eat healthy foods, understand that lifestyle changes can lower your cholesterol, and to take action early by having regular checkups, among other suggestions.
In cases where your 'bad' cholesterol levels are creeping the wrong way despite your best intentions, that's where your doctors can help – and with these new guidelines in place, that could mean changing things up sooner rather than later.
The guidelines are published in the Journal of the American College of Cardiology.
This article was fact-checked by Rebecca Dyer and edited by Rebecca Dyer. While we pride ourselves on our process, we are only human. If you spot a mistake, please let us know.