Updated Cholesterol Guidelines Stress Personalized Care, Healthier Lifestyle

More “personalized” risk assessments and a stronger emphasis on a healthy lifestyle are part of the updated key recommendations in the 2018 cholesterol guidelines from the American Heart Association (AHA) and the American College of Cardiology (ACC).

The new guidelines, presented this month at a conference in Chicago, reaffirms the importance of the risk calculator introduced in the 2013 guidelines as an essential tool to help health care providers identify a patient’s 10-year risk for heart disease. The new approach urges an increased collaboration between doctors and their patients and stresses the importance of lifestyle modifications, including a mostly a plant-based diet, reducing sugar intake, avoiding processed foods, weight management and regular exercise.

The AHA and ACC now urge doctors to talk with patients about “risk-enhancing factors” that can provide a more personalized perspective of a person’s risk, in addition to traditional risk factors such as smoking, high blood pressure and high blood sugar. Those risk-enhancing factors include family history and ethnicity, and certain health conditions such as metabolic syndrome, chronic kidney disease, chronic inflammatory conditions, premature menopause or pre-eclampsia and high lipid biomarkers (a high amount of cholesterol and triglycerides circulating in your blood).

Nearly one of every three U.S. adults have high levels of “low-density lipoprotein cholesterol” (LDL-C), considered the “bad” cholesterol, because it contributes to fatty plaque buildups and narrowing of the arteries. About 94.6 million, or 40 percent, of U.S. adults have total cholesterol of 200 mg/dL or higher. LDL-C (or bad cholesterol) levels of 100 mg/dL or lower are linked to lower rates of heart disease and stroke.

“The updated guidelines reinforce the importance of healthy living, lifestyle modification and prevention,” said Ivor Benjamin, M.D., president of the American Heart Association. “They build on the major shift we made in our 2013 cholesterol recommendations to focus on identifying and addressing lifetime risks for cardiovascular disease.”

While statins are still the first choice of medication for lowering cholesterol, the new recommendations state, new drug options are available for people who have already had a heart attack or stroke and are at highest risk of having another, or for those at a higher risk of having a first heart attack or stroke.

The results of a major study released last month found that adults treated with statins to control cholesterol levels — but still had high levels of triglycerides — had a 25 percent reduction in their relative risk of heart attacks, strokes and other cardiac events after being prescribed high doses of the purified EPA, an omega-3 fatty acid. This new study involved large doses of prescription EPA and had no relation to the fish-oil supplements sold over-the-counter, emphasizes Jonathan Fialkow, M.D., Deputy Medical Director Chief of Cardiology and a certified lipid specialist at Miami Cardiac & Vascular Institute at Baptist Hospital.

“This speaks to the complexity of treating cardiovascular disease,” says Dr. Fialkow. “It’s not just one thing, like LDL-cholesterol. Many factors in a lifestyle can contribute to it, including lack of a good night’s sleep, sedentary lifestyle, highly processed foods. And there are still things we are learning. We should tackle as many things as we can, but people need a healthy lifestyle and decrease environmental factors that can contribute to cardiovascular disease.”

In their updated recommendations, the AHA and ACC stress that high cholesterol, at any age, can increase a person’s lifetime risk for heart disease and stroke. And they emphasize that a “healthy lifestyle is the first step in prevention and treatment to lower that risk.”

Is Your Cholesterol a Problem?

Working with your doctor is the only way to know for sure whether you need treatment, but here are general recommendations from the American Heart Association based on the updated guidelines:

  • Focus on lifestyle. Healthy eating and physical activity are proven to lower LDL cholesterol (the “bad” kind).
  • Be alert early. Take a “lifespan” approach to lower heart disease risk, stroke and other major problems. If there’s a family history, it’s reasonable to test kids as young as 2.
  • Keep monitoring. People over 20 who don’t have cardiovascular disease should have a risk assessment every 4-6 years.
  • People between 40 to 75 are the most likely to need medicine.
  • Among the many factors that could further increase risk:
    1. family history of heart disease or stroke;
    2. high triglycerides;
    3. metabolic syndrome;
    4. chronic kidney disease;
    5. chronic inflammatory conditions, such as rheumatoid arthritis, psoriasis or HIV;
    6. history of pre-eclampsia or early menopause
    7. ethnicity


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