JULY 26, 2026 08:00
For decades, cholesterol has been considered one of the primary risk factors for cardiovascular diseases, but despite high awareness and available treatments, heart disease remains the leading cause of death worldwide. Now, the American College of Cardiology and the American Heart Association are publishing new clinical guidelines, which could change the way millions of people are assessed and treated
The core message of the new recommendations is simple yet significant: It is not enough to treat when cholesterol is already very high or when the person is older. Instead, the risk must be identified as early as possible, adapting the assessment to each individual personally and striving for lower levels of LDL cholesterol, known as “the bad cholesterol.”
The new recommendations, published in the scientific journals of the cardiology associations, are based on a large accumulation of studies from recent years, showing that the lower the LDL level throughout life, the smaller the risk of heart attacks, stroke, and heart failure
Until now, most medical decisions focused mainly on cholesterol values, blood pressure, and age. However, the new approach significantly expands the risk picture
Among other things, doctors are requested to also refer to a family history of heart disease, inflammatory diseases such as rheumatoid arthritis, as well as conditions unique to women such as preeclampsia, gestational diabetes, and early menopause, which have been found to increase cardiovascular risk throughout life
Another factor is also receiving a central place now, which is Lipoprotein(a), or Lp(a), a protein with a significant genetic component that was considered for years to be less known to the general public
According to the new recommendations, it is recommended to perform an Lp(a) test at least once in a lifetime. Studies indicate that high levels of it may increase the risk of heart disease by about 40 percent and even double it at especially high concentrations
One of the significant innovations is the emphasis on diagnosis at a younger age. Thus, for example, in children and adolescents with suspected familial hypercholesterolemia, a genetic disease that causes very high levels of LDL already at a young age, they recommend starting tests around age nine and even earlier in certain cases
The goal is to prevent long years of exposure to a cholesterol load that could cause the accumulation of atherosclerosis in the arteries already from a young age
According to the authors of the guidelines, lowering cholesterol and blood pressure already in one’s 20s and 30s could affect the health of the heart and arteries throughout life
Until now, doctors relied on a model that calculated the risk for the next ten years mainly according to age, blood pressure, and cholesterol
Now, it is proposed to use a new model called PREVENT, which allows for evaluating the risk for the next 30 years as well. The new model is based on data from about 6.6 million people, compared to only about 26,000 on whom the old model was based, and it also includes data on sugar levels and kidney function. The meaning is a more accurate and personal assessment of the future risk, even in relatively young people
Despite the progress in medications and tests, the experts emphasize that the foundation for preventing heart disease has not changed: A balanced diet, regular physical activity, avoiding smoking, sufficient sleep, and maintaining a healthy weight continue to be the most important tools
According to estimates, between 80 and 90 percent of heart diseases are related at least in part to risk factors that can be modified through a healthy lifestyle
The treatment targets are also becoming more ambitious. In people without known heart disease, a desirable LDL level remains below 100 milligrams per deciliter
However, in people at moderate risk, they now recommend striving for less than 70 milligrams per deciliter, and in those with high risk, the new target is less than 55 milligrams per deciliter. In addition, the guidelines include reference to additional metrics such as Non–HDL Cholesterol and Apolipoprotein B, which may provide a better picture of the cardiovascular risk
Alongside the familiar statin drugs, the guidelines also refer to additional treatments such as ezetimibe, bempedoic acid, and PCSK9 inhibitors, which are intended for people who do not reach their cholesterol targets through statins alone or need a combined treatment
The trend is clear: Personalization of the treatment for each patient according to the risk level and the response to treatment
What does this mean for the public? The main message of the new guidelines is not that every person needs to immediately start drug treatment, but rather that every person needs to know their personal risk factors better
If a family history of early heart disease exists, if additional risk factors exist, or if the cholesterol values are high, it is advisable to consult a family doctor or cardiologist regarding the need for a more comprehensive evaluation
The experts conclude that the future of heart medicine does not begin in the emergency room after a heart attack, but many years earlier, through early identification, personalized treatment, and the adoption of a healthy lifestyle. The earlier the intervention begins, the greater the chance to maintain a healthy heart and blood vessels in the coming decades as well
