Start cholesterol tests in childhood, new guidelines say

New heart health recommendations emphasize early testing and treatment to lower cholesterol levels as key to reducing the risk of cardiovascular disease. 

A group of 11 medical associations including the American College of Cardiology and the American Heart Association released new guidelines on March 13 to help doctors and their patients manage cholesterol levels. The recommendations advise first testing cholesterol in childhood, around age 10, with the aim of helping patients keep levels low, reducing the chances a heart attack or a stroke might happen decades in the future. Also new is a cardiovascular risk calculator called PREVENT that is designed to assess heart attack and stroke risk over the next 10 and 30 years in adults 30-79 years old who don’t already have heart disease. 

The previous recommendations, released in 2018, relied on another calculator that was based on clinical data from a cohort of around 25,000 adults who participated in U.S. National Institutes of Health-sponsored studies, says Roger Blumenthal, a cardiologist at Johns Hopkins School of Medicine. That calculator looked forward just 10 years. What’s more, the guidelines did not have specific cholesterol benchmarks for people with different levels of risk based on family or medical history. 

PREVENT, on the other hand, is based studies that included a total of 6.6 million people, helping to better estimate short- and long-term risks on an individual basis, Blumenthal says. The new guidance also emphasizes additional tests that are not part of the standard cholesterol blood test, or lipid panel, including a one-time assessment of lipoprotein(a), or Lp(a). Levels of Lp(a) are determined by genetics and can increase the long-term risk of heart attack or stroke. 

Roughly a quarter of U.S. adults have high levels of low-density lipoprotein, or LDL, cholesterol. Reducing these “bad” cholesterol levels with lifestyle changes such as healthy eating and exercise or with medications can lower the risk of cardiovascular disease, the leading cause of death globally. 

Science News spoke with Blumenthal, who chaired the guideline writing committee, to learn more about the new recommendations and how the shifts might impact treatment. This conversation has been edited for length and clarity. 

SN: What are the most important changes in the guidelines? 

Blumenthal: I’ll start with number one, which essentially is to assess and treat early. We recommended — especially if there’s any family history of heart disease, or if there’s another cardiovascular risk factor — that the clinician should screen with a lipid panel around age 10 and again around age 20 and then every five years after that. 

We also made the point that, especially if you’re age 30 and above and your LDL cholesterol is 160 or higher on successive occasions, it certainly makes sense to consider starting a cholesterol-lowering medication if there’s a family history of heart disease or other risk factors. 

We now have a more robust and more accurate risk estimator that we call PREVENT. I think one of the best things about PREVENT is that we have a good way to estimate long-term risk. We can tell [patients with certain risk factors] that while their risk over the next 10 years is really low, their risk over the next 20 to 30 years is quite high.

If there’s a family history of cardiovascular disease, even if your estimated risk in your 30s is quite low, clinicians should talk to their patients about [healthy lifestyle habits]. Many young adults in their 30s and 40s have a very low 10-year risk because so much of the PREVENT score is based on chronological age rather than biologic age. But we can now estimate 30-year risk. If you have a person in front of you who it says the [10-year] risk is one or two or three percent, but [the calculator can] tell them that if you don’t change your lifestyle habits, if you don’t improve your weight, your cholesterol, your blood pressure, your 30-year risk may very well be 30 percent, that gets their attention. 

SN: What are the most important benchmarks that people should know about? 

Blumenthal: The key numbers to remember are LDLs of 100, 70 and 55. We state that in all borderline risk individuals — and really I would say for all adults — that we like them to strive to improve their lifestyle habits so that they can lower their LDL down to the range of 100 milligrams per deciliter or less. We know that individuals who may have some evidence of mild to moderate atherosclerotic disease or have multiple risk factors very well may want to try to get their LDLs down in the 70 mg/dL range. [For high-risk individuals] we have good data that getting their LDLs closer to the 55 mg/dL range is preferable.

A one-time measurement of lipoprotein(a) can be a helpful tie breaker [for risk assessment, even if other lipid levels are normal]. We put in the guidelines that if your Lp(a) is [above a certain threshold] that your risk probably is twice as high as what the PREVENT score is estimating. 

We also stated that there are certain high-risk groups for clinicians to remember: those who have diabetes, chronic kidney disease or HIV infection. We have really good data that if their LDLs are suboptimal, that treatment with statin therapy in addition to more aggressive lifestyle changes makes a lot of sense.

SN: Why did you and the committee decide to make these changes?  

Blumenthal: One, we have a more accurate risk calculator. Two, we wanted to follow the same logic that the American Heart Association and the American College of Cardiology did with the recent blood pressure guidelines. They said that if, even after six months of lifestyle improvement attempts, your blood pressure stays above 130/80 that you should give strong consideration to going on a medication. We felt that with that same proactive approach — that if an individual is 30 years and older and has persistently higher LDL cholesterol — that [considering medication] makes sense. 

SN: Is that why there is a focus on treating early? 

Blumenthal: It’s really important to start health behavior counseling in youth. Pediatricians generally have that strong ethos in prevention. My late father was a pediatrician. I think a lot of my interest in preventative cardiology stems from my discussions with him about [how] the habits that one develops in youth or adolescence generally are the habits that [one] will follow later on.