New Guidelines for Managing Cholesterol and Other Blood Lipids

The American Heart Association, the American College of Cardiology and nine other leading medical associations recently issued new guidelines for managing dyslipidemia—abnormal levels of cholesterol, triglycerides or other lipids in the bloodstream.

The guildlines have arrived not a moment too soon. It is estimated that 1 in 4 U.S. adults has high levels of low-density lipoprotein-cholesterol (LDL-C). Known colloquially as “bad” cholesterol, high LDL-C increases a person’s risk of heart attack and stroke, medical emergencies that live under the umbrella of atherosclerotic cardiovascular disease (ASCVD).

ASCVD is caused by a buildup of fatty deposits in the arteries. It’s the leading cause of death, both nationally and globally.

The good news is that 80 percent of cardiovascular disease is preventable.

The role of primary care

“Primary care clinicians are really the backbone of patient care, especially when it comes to cardiovascular prevention. We’re uniquely positioned to reinforce healthy behaviors related to diet, exercise, sleep and smoking,” said Dr. Madeline R. Sterling, an internist and associate professor of medicine at Weill Cornell Medicine and a lead author of the document.

Its central message, after all, is earlier intervention through healthy lifestyle changes, including:

• maintaining a healthy weight
• engaging in regular physical activity
• avoiding smoking and tobacco products generally
• prioritizing healthy sleep habits

Optimizing healthy lifestyle habits is the first step. But if lipid numbers don’t come down after giving lifestyle changes a chance, your provider may recommend adding a statin to your heart-healthy regimen.

A new cardiovascular risk calculator

Called PREVENT, the new risk assessment tool categorizes patients into four groups, ranging from low to high. Risk calculation is based on health information gathered during your annual physical, from blood pressure to cholesterol, along with your age and health habits.

A number of other factors may further exacerbate ASCVD risk:

• a family history of heart disease
• a chronic inflammatory condition (e.g., lupus or rheumatoid arthritis)
• a metabolic condition (e.g., obesity, diabetes or chronic kidney disease)
• South Asian or Filipino ancestry
• reproductive risk markers, including early menopause (between ages 40 and 45), preeclampsia and gestational diabetes

In an effort to go deeper, specialists may decide to use additional markers to refine their assessment of a patient’s risk:

• lipoprotein(a) – a genetic type of LDL
• apolipoprotein B – a protein found on the surface of LDL cholesterol molecules
• high sensitivity C-reactive protein
• elevated triglycerides

Clearly, all of the above potential markers of cardiovascular disease risk go way beyond the basics of “good” and “bad” cholesterol.

Additional tests

To see whether aiming for a lower LDL-C target may be warranted, and whether a more intensive approach is needed to mitigate cardiovascular disease risk, your provider may order one or more of the following tests:

• a coronary artery calcium scan to check for early calcium and plaque build-up in the walls of the heart’s arteries
• lipoprotein(a), which should be measured at least once in adulthood
• apolipoprotein B to guide treatment among people with cardiovascular-kidney-metabolic syndrome, type 2 diabetes, high triglycerides or known cardiovascular disease; or people whose lipid goals have been met but continue to be at risk.

Non-statin therapies

If LDL-C levels remain stubbornly high despite healthy lifestyle changes and statin therapy, the updated guidelines recommend adding a non-statin medication. Options include ezetimibe and/or bempedoic acid or a PCSK9 monoclonal antibody (an injectable therapy). Another injectable option is inclisiran, which is still being studied in clinical trials.

What about high triglycerides?

Lifestyle changes and statins are still the mainstay for treating high triglycerides. However, other therapies may be needed, based on a person’s cardiovascular disease and pancreatitis risk.

High cholesterol in children and teens

Whether the culprit is the American diet, a sedentary lifestyle or genetics, even children and adolescents can fall prey to high cholesterol. The new guidelines recommend cholesterol screening for children between the ages of 9 and 11 to help assess risk and guide care.

Where America’s young people are concerned, the approach needs to be a partnership between clinicians, parents and caregivers.

It all starts with lifestyle modification. That’s the cornerstone of prevention and risk reduction.

With PREVENT ( the new risk assessment tool), selective use of calcium scoring and measuring lipoprotein(a), specialists aim to reduce the burden of ASCVD and save many lives, both now and in the future.

A challenge that will require a team-based approach

It won’t be easy to get patients and providers on board with the new guidelines, Dr. Sterling says. A team-based approach will be needed; one in which nurses, pharmacists and specialists help patients manage medications and reach cholesterol targets.

As well, she adds, successful adoption of the new guidelines will likely require better insurance coverage, improved electronic health record tools, patient education efforts and stronger collaboration between primary care clinicians and specialists, along with research and implementation efforts.

Make an appointment with a cardiologist at Weill Cornell Medicine by calling (646) 962-5558 or by visiting the department’s website here.