New Delhi: Heart disease remains the leading cause of death worldwide, and doctors now recommend that the risk of a heart attack or stroke should be assessed much earlier in life.
New cholesterol guidelines released Friday by the American College of Cardiology and the American Heart Association, along with nine other medical organisations, recommend starting to test for “bad” cholesterol during childhood, at around age 10.
These guidelines aim at early detection and treatment of dyslipidemia—unhealthy levels of fats in the blood.
“Screening at ages 9 to 11 years is recommended because subclinical atherosclerosis, as assessed by carotid intimal medial thickness, may be detected as early as 8 to 10 years of age, and because screening later in adolescence is less optimal due to declines in total cholesterol (TC) and LDL-C levels of 10% to 20% during mid- to late puberty before rising to adult levels,” said the guidelines.
Subclinical atherosclerosis refers to the early build-up of fat in the arteries without causing any symptoms yet. Doctors can spot it early using an ultrasound to check if the artery walls have thickened.
Low-density lipoprotein (LDL), often called “bad cholesterol”, can slowly build up in the arteries and form plaque. Over time, this can narrow blood vessels and raise the risk of heart attacks and strokes. Because this damage develops silently over many years, doctors say detecting high cholesterol early is key to preventing heart disease later in life.
The guidelines classified people into low, moderate, high and very high risk groups. LDL cholesterol should be below 100 mg/dL for low- or moderate-risk individuals, below 70 mg/dL for high-risk patients, and below 55 mg/dL for very high-risk individuals, such as those who have already had heart attacks or multiple stents.
According to the authors of the guideline, around one in four adults in the US has high levels of bad cholesterol.
“We know 80 percent or more of cardiovascular disease is preventable, and elevated LDL cholesterol is a major part of that risk. Lowering LDL cholesterol earlier and keeping it low for longer significantly reduces the chances of future heart attacks and strokes,” said Dr Roger Blumenthal, director of the Johns Hopkins Ciccarone Center for the Prevention of Heart Disease and the Kenneth J. Pollin Professor of Cardiology at Johns Hopkins Hospital in Baltimore.
“While we want to try to optimise healthy lifestyle habits as the first step to lower cholesterol, we realise that if lipid numbers aren’t within the desirable range after a period of lifestyle optimisation, we should consider adding lipid-lowering medication earlier than we would have considered 10 years ago. And lower LDL cholesterol for longer, just like lower blood pressure for longer, results in much greater protection against future heart attack and stroke risk,” added Blumenthal, who chaired the guideline writing committee.
What’s new?
One of the biggest changes in the new guidelines is the return of clear numerical targets for LDL cholesterol. Earlier guidelines published in 2018 focused mainly on reducing LDL levels by a certain percentage.
Commenting on the significance of the new global guidelines, Dr Suman Bhandari, president of the Delhi Chapter of the Cardiological Society of India (SCI), said the change gives doctors clearer treatment goals.
“Earlier, the focus was mainly on reducing LDL by about 50 percent, but now specific numbers have been given,” he said.
The guidelines also introduce a newer, more contemporary cardiovascular disease risk calculator—Predicting Risk of Cardiovascular Disease EVENTs (PREVENT)—to estimate a person’s chances of developing heart disease.
The calculator predicts both the 10-year and 30-year risk of heart attack or stroke in adults aged between 30 and 79 who do not already have cardiovascular disease.
It uses information typically collected during routine health check-ups, including cholesterol levels, blood pressure and lifestyle habits. This system replaces an older method known as the Pooled Cohort Equations, which researchers found often overestimated heart disease risk.
Additional tests
The updated guidance also highlights several additional tests that can help doctors better understand cardiovascular risk.
One is lipoprotein(a), or Lp(a), a cholesterol particle that is largely determined by genetics. The guidelines recommend that every adult have their Lp(a) level measured at least once in their lifetime.
Another marker doctors may consider is apolipoprotein B (apoB), which reflects the number of cholesterol-carrying particles circulating in the blood.
A coronary artery calcium scan is also highlighted as a useful tool. This scan detects early calcium buildup in the arteries of the heart, which signals that plaque has already begun forming.
Dr Bhandari said the test can now guide not only whether treatment is needed but also how much cholesterol should be lowered.
“Doctors already knew that higher calcium scores are linked to a higher risk of future heart problems, but earlier guidelines did not clearly say what LDL levels patients should aim for based on that score,” he said.
Why recommendations matter for India
Cardiologists say the focus on earlier prevention may be particularly important for India, where heart disease often develops at younger ages.
According to Dr Bhandari, cholesterol screening may need to start earlier for Indians.
“For India, lipid testing is often recommended from around 30 years of age, but I think it should start closer to 18 years,” he said. “This buildup of cholesterol begins very early, even in the first decade of life.”
He added that schools could also help in early detection by monitoring students’ weight, diet and lifestyle habits during adolescence.
South Asians—including Indians, Pakistanis and Bangladeshis—are widely recognised as a high-risk group for heart disease.
The 2023 guidelines for dyslipidemia management, issued by the Cardiological Society of India, broadly aligned with global guidelines but emphasised strict LDL targets because Indians tend to develop cardiovascular disease earlier.
“Similar guidelines are available in India as well, but calcium scoring was not highlighted in the Indian guidelines,” Dr Bhandari said.
Doctors may add other medicines
Treatment options for high cholesterol have also expanded in recent years. Statins, the prescription drugs people take to lower their level of LDL, remain the most commonly used medicines to reduce LDL cholesterol.
The new guidelines say that if statins alone do not work sufficiently, doctors may add other medicines. These include ezetimibe, which helps reduce the amount of cholesterol the body absorbs from food, and Bempedoic acid, a newer pill that helps the liver make less cholesterol.
For people at high risk of heart disease, doctors may also use injectable medicines called PCSK9 inhibitors, which help the body remove “bad” cholesterol from the blood more effectively.
Another injectable treatment, inclisiran, is still being studied to see how well it helps prevent heart attacks and strokes.
Lifestyle changes still best remedy
Despite advances in medicines and testing, doctors stress that lifestyle changes remain the foundation of prevention.
“Previously, the focus was primarily on controlling LDL levels, but current guidelines suggest the control of all components of lipid profile,” said Shiv Kumar Chaudhary, Executive Director of Cardio Thoracic Vascular Surgery at Fortis Escorts Heart Institute.
“Lifestyle remains the foundation of lipid management — healthy diet, weight control, and physical activity are essential for preventing cardiovascular disease,” he added.
The guidelines also caution against relying on dietary supplements marketed for heart health.
Products such as fish oil, red yeast rice and plant sterols are often promoted as cholesterol-lowering remedies, but the fresh guidelines do not recommend their use, saying that the evidence for their benefits remains limited.
“Diet itself works—you don’t really need supplements,” said Dr Bhandari, adding that healthier oils, reduced saturated fats and balanced diets can help lower cholesterol levels.
(Edited by Sugita Katyal)