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By Amanda Greenwood
Associate News Editor
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Americans may soon be advised to start paying closer attention to their cholesterol levels much earlier in life, under sweeping new guidelines released by the American College of Cardiology (ACC) and the American Heart Association (AHA).
The updated guidance, published March 13 in the Journal of the American College of Cardiology (JACC) and Circulation, replaces the 2018 cholesterol guidelines and reflects a major shift in how doctors are encouraged to assess and manage cholesterol-related heart disease risk.
At the center of the update is a push for earlier screening, earlier intervention, and a stronger focus on lifetime cardiovascular risk, rather than waiting until middle age when heart attack and stroke risks become more apparent.
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Why the Guidelines Changed
Roughly one in four U.S. adults has elevated LDL cholesterol, often referred to as "bad" cholesterol, which increases the risk of heart attack and stroke, according to the ACC, which also states that cardiovascular disease remains the leading cause of death in the United States and worldwide.
Roger Blumenthal, MD, FACC, FAHA, chair of the guideline writing committee, said in a press release that: "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."
In what the ACC describes as a "one‑stop shop" for keeping the fats in the blood at a healthy level across a patient’s life span, the new guideline puts all the best medical advice about cholesterol and other blood fats into one easy‑to‑use guide for doctors.
This means that instead of having to look at several different rules or documents, clinicians can now find everything in one place to help them check cholesterol levels and decide on the best treatment.
Screening Starts Earlier
One of the most significant changes is the recommendation that doctors begin screening and considering treatment for cholesterol in people as young as their 30s, particularly those with persistently high LDL, or "bad," cholesterol.
Rather than focusing solely on a patient’s short‑term risk, clinicians are now being encouraged to evaluate the patient’s long‑term exposure to unhealthy cholesterol levels, which could cause future heart attacks and strokes.
To support this shift, the guideline recommends they use a new risk calculator known as PREVENT‑ASCVD, which estimates both 10‑year and 30‑year cardiovascular risk for adults ages 30 to 79.
Blumenthal said: "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."
New Tests Added to Standard Cholesterol Checks
For the first time, the ACC and AHA are also recommending routine consideration of additional blood tests that can reveal hidden heart risks not always captured by standard cholesterol panels.
According to Blumenthal, "Measuring other biomarkers can give a more complete picture of someone's cardiovascular risk and help inform decisions about whether lipid-lowering therapy is needed sooner rather than later or if more intensive therapy is warranted."
Cholesterol Targets Return
Another notable shift is the return of specific cholesterol targets, which had been de-emphasized in previous guidance.
Doctors now set cholesterol goals based on how likely someone is to develop heart disease.
- People with some risk should try to keep their "bad" cholesterol under 100.
- People at high risk should aim for under 70.
- People who already have heart disease and are at very high risk should keep it under 55.
Pamela Morris, MD, FACC, FAHA, and vice-chair of the guideline writing committee, said, "In general, lower LDL is better, especially for people at increased risk for a heart attack or stroke."
Lifestyle First, Medication Earlier When Needed
While the guidelines continue to emphasize diet, exercise, weight management, and avoiding tobacco as the foundation to try to prevent heart disease, they also support earlier use of cholesterol‑lowering medications, such as statins, when lifestyle changes alone are not enough.
"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," Blumenthal said.
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