Updated Guidelines for Managing Blood Lipids and Cholesterol Unveiled
Top health associations in the United States have released an updated set of guidelines on how to manage dyslipidemia – a condition marked by abnormal levels of lipids or lipoproteins in the blood, including cholesterol and triglycerides. High levels of low-density lipoprotein-cholesterol (LDL-C), also known as the "bad" cholesterol, can increase the risk of heart attack and stroke, and are found in about 25% of American adults.
A Comprehensive Guide to Managing Dyslipidemia
The new guideline provides a comprehensive resource for healthcare professionals on how to assess and treat various blood lipids to effectively lower a person’s risk of developing atherosclerotic cardiovascular disease (ASCVD). ASCVD, caused by a buildup of fatty deposits in the arteries, is the leading cause of death worldwide.
Emphasis on Early Intervention and Lifestyle Changes
A significant focus of the guideline is early intervention through healthy lifestyle changes. These include maintaining a healthy weight, regular physical activity, avoiding tobacco products, adopting healthy sleep habits, and taking cholesterol-lowering medication when advised by a healthcare professional. The guideline also reinforces the need for lower LDL-C goals and reduces percentage based on risk to minimize lifetime exposure to unhealthy lipids and risk of heart attack and stroke.
Experts note that while healthy lifestyle habits are the first step to lowering cholesterol, if lipid numbers don't fall within the desirable range after a period of lifestyle optimization, the addition of lipid-lowering medication should be considered earlier than previously thought.
New Risk Calculator Introduced
The updated guideline includes a new, more contemporary cardiovascular disease risk calculator for primary prevention of ASCVD. The calculator, called the Predicting Risk of Cardiovascular Disease EVENTs (PREVENT), is designed for adults aged 30-79 years without known ASCVD or subclinical atherosclerosis and with LDL-C levels between 70–189 mg/dL. The tool estimates 10- and 30- year risk of heart attack or stroke and guides lipid-lowering therapy.
Older risk scores overestimated the 10-year risk of a heart attack and stroke by 40%-50%. The updated PREVENT-ASCVD equations classify 10-year ASCVD risk into several categories, which then guide treatment decisions.
Personalizing Risk Scores
The new assessment tool helps estimate cardiovascular risk using health information already obtained during an annual physical, such as cholesterol and blood pressure readings, along with other personal information like age and health habits. This information is then further personalized by looking at ‘risk enhancers,’ which can help guide the need for lipid-lowering therapy.
These risk enhancers include factors like a family history of heart disease, chronic inflammatory conditions, cardiometabolic conditions, higher-risk ancestry, and reproductive risk markers. Additional markers, including lipoprotein(a), apolipoprotein B, high-sensitivity C-reactive protein, and elevated triglycerides, can be used to refine an individual’s ASCVD risk.
Additional Tests for a More Complete Risk Assessment
The new guideline recommends the consideration of additional tests, when appropriate, to improve cardiovascular risk assessment. These include a non-contrast coronary artery calcium (CAC) scan, measuring lipoprotein (a) at least once in adulthood, and measuring apolipoprotein B to assess any residual ASCVD risk.
Lowering LDL-C for Preventing Heart Attack or Stroke
The guideline highlights that LDL-C levels should be less than 100 mg/dL for those at borderline or intermediate risk and less than 70 mg/dL in those at high risk to prevent a first heart attack or stroke. For individuals with ASCVD who are at very high risk of ASCVD events, the LDL-C goal should be less than 55 mg/dL for secondary prevention of cardiac events.
If LDL-C levels are not adequately lowered by healthy lifestyle habits and statin therapy, the guideline recommends the addition of non-statin therapies. These therapies depend on the level of risk and patient characteristics and include options like ezetimibe, bempedoic acid, or a PCSK9 monoclonal antibody.
Special Considerations for Certain Adults at Increased Risk of Heart Disease
The guideline also recommends special considerations for certain adults at increased risk of heart disease. These include initiating lipid-lowering therapy for people aged 40 or older with chronic kidney disease, HIV, or Type 1 or Type 2 diabetes, and continuing lipid-lowering therapy in people being treated for cancer, unless contraindicated.
High Cholesterol in Children
Lastly, the guideline notes that high cholesterol can begin to impact heart disease risk even in childhood and adolescence. All children between the ages of 9-11 years are recommended to have a cholesterol screening to help assess risk and guide care.
Experts emphasize that early action is critical because high cholesterol begins to impact heart disease risk even in adolescence. Implementing these guidelines will be crucial to reduce the future burden of cardiovascular disease.