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I REGULARLY DISCUSS cholesterol with my patients, and many of them roll their eyes, knowing I’m about to suggest yet another pill. But the new cholesterol guidelines—which recommend treating your cholesterol earlier and more frequently—were created based on clinical trials that suggest this approach can more effectively reduce the risk of heart attack or stroke.

Why the change to being more aggressive about treating high cholesterol? In part, because the prevalence of other heart risk factors, like hypertension and diabetes, continues to rise among younger adults. As a result, it’s become more important than ever to keep other modifiable risk factors, like cholesterol, tightly controlled.

The new guidelines, issued jointly by major organizations including the American Heart Association and American College of Cardiology, change a few things your doctor might suggest. The 150 specific consensus recommendations based on scientific evidence heavily influence medical practice, insurance coverage, and public health policies.

So if your doctor suddenly starts talking more about your cholesterol, it’s a sign not only that they care about your future, but also that they’re current with best practices. And if you worry about taking statins to control your cholesterol, what if I told you that just ten extra seconds each day spent opening a bottle and swallowing a pill – a total of about 40 hours over the course of your lifetime – could add up to two years of life? Not a bad investment at all. Here are the top-level bullets I share with patients:

You Might Need Medication…

…if you’re 30 or older, and your cholesterol is mildly elevated.

Even those with mildly elevated cholesterol, defined as LDL > 100 mg/dl, shouldn’t wait to treat it. Earlier and longer exposure to high cholesterol results in greater lifetime risk; doctors view cumulative “cholesterol-years” as an important risk factor. In other words, someone with mildly elevated cholesterol for decades is worse off than someone who develops moderately elevated cholesterol later in life.

Of course, this assumes you know your cholesterol. The guidelines have your back here. They say it should be measured at around age 10, then 19, and then repeated at least every five years thereafter. Since this is standard preventive healthcare, your insurance should cover it for free.

And don’t just assume your numbers are fine because you optimize your health. As a cardiologist, I regularly see patients with ideal lifestyles and concerningly high cholesterol. Like high blood pressure, high cholesterol doesn’t cause any symptoms, and it can sneak up on people who otherwise appear healthy. About one in 250 people has a genetic mutation that elevates cholesterol even despite ideal diet and exercise.

…even if your LDL was considered OK last year—and it’s still the same number.

For most people, levels of LDL (“bad cholesterol”) are the most important value in the cholesterol panel and the strongest predictor of heart attack and stroke risk. In addition, the goalposts are moving on when you need to take action to lower it.

How aggressive you and your doctor should be about lowering it depends on how high your risk is of having a heart attack or stroke. Previous guidelines recommended lowering cholesterol but didn’t set treatment goals. Now, LDL should be 100 mg/dl or less in people at intermediate risk, 70 mg/dl or less for those at high risk, and 55 mg/dl or less for those at very high risk. These recommendations are based on numerous studies finding that lowering LDL continues to lower risk, even when it’s well below the “normal” threshold of 100 mg/dl. If you’re particularly risk averse, it’s reasonable to target a lower LDL level than the one corresponding to your risk level.

If you want to know how your risk category is determined here’s more:

• If you’ve never had a heart attack or stroke, your risk is estimated with a calculator—known as the PREVENT calculator. It’s freely available online and takes into account not just your cholesterol and blood pressure, but also kidney function and some social factors. Most of the numbers you need to plug into it are obtained from a routine lab panel. The calculator produces a 10-year risk of heart attack or stroke, and puts you into one of four categories: low (<3%), borderline (3-5%), intermediate (5-10%) and high (>10%).

• If you have had a heart attack or stroke, your risk is at least high. It’s considered very high if you’ve had multiple heart attacks or strokes, or if you’ve had one of those plus two additional risk factors (such as diabetes, smoking, age > 65, heart failure).

Are Statins Safe?

MANY PATIENTS DOING their best with lifestyle changes (including more than 150 minutes of exercise a week, and a diet focusing on fruits, vegetables and whole grains) will nonetheless also require medications. Statins are still first-line treatments for most people, and they are far safer than most people think. The benefits are robust and significant, while the risks are often exaggerated.

Numerous studies have identified the benefits and risks of statins. The WOSCOPS trial, for example, randomized 6,595 adult men with high cholesterol and no history of heart disease to either pravastatin or placebo for five years, then followed them for 20 years. Those who took pravastatin—for only five years—saw a 24 percent reduction in heart attack and 13 percent reduction in death 20 years later, highlighting a long-term benefit from earlier intervention.

Meanwhile, another study examined the “nocebo” (short for “negative placebo”) effect of statins by enrolling people who said they experienced statin intolerance. Each month, the participants were randomly assigned to take atorvastatin, placebo, or nothing. The atorvastatin and placebo doses looked identical, and participants didn’t know which was which. The group reported significantly more muscle symptoms with both atorvastatin and placebo compared to no tablets. And they reported a similar number of symptoms whether they took a statin or the placebo.

Some patients, upon receiving a recommendation for statin, accuse me of being a shill for pharmaceutical companies. Although the original research programs were sponsored by the pharmaceutical companies—as is standard practice across drug categories—these drugs became generic long ago, and ongoing, independent clinical trials continue to support their benefits. Although it is true that these medications have sometimes been overprescribed, the new guidelines encourage open discussion about risk during appointments and individualized care, especially for those in the “intermediate” risk category.

Finally, I explain to patients that the benefits are invisible – you don’t know about the heart attacks you didn’t have – whereas the side effects, though rare, are noticeable. The most common ones are muscle or joint aches, which typically resolve after switching to a different medication. Serious side effects, such as overt muscle inflammation, are extremely rare (<1 in 10,000). About 3 to 5 percent of people are unable to tolerate statins and instead take medications from other drug classes, such as PCSK9 inhibitors (Repatha, Praluent).

Can’t I Just Use Supplements?

ALTHOUGH MANY SUPPLEMENTS advertise positive effects on cholesterol and overall heart health, such statements are just marketing and not based on clinical evidence. In fact, a large, randomized trial comparing rosuvastatin to garlic, fish oil, red yeast rice, cinnamon, and turmeric found that only rosuvastatin yielded a meaningful reduction in cholesterol. As a result, the guidelines explicitly recommend against over-the-counter supplements for cholesterol treatment. I would happily recommend any supplement that stood up to scrutiny. So far, none has.

What’s Up With the Extra Tests Now?

WHILE LDL IS still the most important marker of risk, the lipid guidelines recommend additional tests that can further clarify risk.

• The other test everyone should get: lipoprotein(a). This lipid particle, also known as Lp(a), is a known risk factor for cardiovascular disease, but awareness among physicians has been inconsistent, and its role in risk assessment has been loosely defined. Moreover, there were previously no medications that specifically lower Lp(a) levels. Now, the guidelines recommend that everyone get their levels checked, because higher values favor earlier and more aggressive cholesterol treatment.

Because lipoprotein(a) is genetically determined and not significantly affected by available medications, you only need to measure it once. New medications that can significantly lower Lp(a) levels are being studied in clinical trials to assess their impact on heart disease and overall survival. If the studies are positive, expect to hear much more about them.


• You might also get a CT scan to measure your calcium score. This scan quantifies the calcified plaque in the heart—you know, the gunk lurking in your arteries, waiting to cause a heart attack—and robustly predicts future risk.

The score ranges from zero, meaning no calcified plaque, to the thousands; a higher score means more plaque. The calcium score has long been recommended for those at intermediate risk to help determine their need for treatment.

The new guidelines add that calcium scoring can also be performed in those taking cholesterol medications to further clarify their treatment goals. The higher your score, the lower your LDL should be. If you’re into the details, here’s what that looks like: A calcium score of 1 to 100 translates to an LDL goal of < 100; a score of 100 to 999 to an LDL goal of < 70 mg/dl; a score of >1000 to a goal of < 55 mg/dl.

The next time you see your doctor, don’t be surprise if you set a new course of action together to take down your heart risk and improve your life.

Headshot of Christopher Kelly M.D.
Christopher Kelly M.D.
Author

Christopher Rehbeck Kelly, M.D., M.S. is a cardiologist at UNC Rex Hospital in Raleigh, NC. He serves on the board of the American Heart Association in North Carolina and is the founder of Exact Healthcare. He graduated from the Columbia University College of Physicians and Surgeons and served as an intern, resident, and chief resident at NewYork-Presbyterian Hospital/Columbia University Irving Medical Center. He is co-author of the book, Am I Dying?!: A Complete Guide To Your Symptoms, and What to Do Next.