BATON ROUGE — New guidelines could change how millions of Americans manage their cholesterol, with doctors now urging earlier action to prevent heart attacks and strokes. The recommendations come from the American College of Cardiology (ACC) and the American Heart Association (AHA), along with several other leading medical groups.
The new guidelines focus on people with unhealthy cholesterol and other fats in the blood, a condition known as dyslipidemia. It’s estimated that one in four U.S. adults has high levels of low-density lipoprotein cholesterol (LDL-C), which increases the risk of heart attack and stroke.
New guidelines
A major focus of the new guidelines is earlier intervention through lifestyle changes. That includes maintaining a healthy weight, regular physical activity, avoiding tobacco products, prioritizing healthy sleep habits, and taking cholesterol-lowering medication when it’s recommended by a health care professional.
“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,” said Roger Blumenthal, MD, FACC, FAHA, chair of the guideline writing committee, director of the Johns Hopkins Ciccarone Center for the Prevention of Heart Disease and the Kenneth J. Pollin Professor of Cardiology at Johns Hopkins Hospital in Baltimore.
“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,” Dr. Blumental continued. “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.”
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PREVENT
There’s also a newer, more contemporary cardiovascular disease risk calculator being added to the dyslipidemia guidelines, called Predicting Risk of Cardiovascular Disease EVENTs (PREVENT). PREVENT is now recommended for the primary prevention of atherosclerotic cardiovascular disease (ASCVD).
The PREVENT-ASCVD equations are for adults 30-79 years old who don’t have ASCVD or subclinical atherosclerosis and with LDL-C 70–189 mg/dL. It is used to estimate the 10 and 30-year risk of heart attack or stroke. It also helps guide lipid-lowering therapy like statins and other new treatments.
“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 said.
Risk enhancers include family history of heart disease, chronic inflammatory conditions, cardiometabolic conditions like being overweight, diabetes, or kidney disease. People who have a South Asian or Filipino ancestry are also ay a higher-risk, as well as other ancestral groups with an enhanced risk for developing atherosclerosis.
Additional testing
The new guidelines also recommend people consider additional tests, when appropriate, if more intensified LDL-C lowering is needed. These include selective use of a non-contrast coronary artery calcium (CAC) scan, Lipoprotein (a), and Apoliporotein B.
The CAC scan can check for early calcium and plaque buildup in the walls of a heart’s arteries, when a person’s true risk is uncertain. It’s recommended for men 40 and older, and women 45 and older with borderline or intermediate 10-year risk of heart attack and stroke.
Lipoprotein (a) should be measured at least once in adulthood. These levels are largely genetically determined and remain relatively stable over a lifetime. High Lp(a) is associated with an increased long-term risk of heart attack or stroke.
Apolipoprotein B can be reused to assess residual ASCVD risk and guide treatment for people who have cardiovascular kidney-metabolic syndrome, type 2 diabetes, high triglycerides, or known cardiovascular disease.
“In general, lower LDL is better, especially for people at increased risk for a heart attack or stroke,” said Pamela B. Morris, MD, FACC, FAHA, vice-chair of the guideline writing committee and the Paul V. Palmer chair of cardiovascular disease prevention and director of the Seinsheimer Cardiovascular Health Program at 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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