New Guidelines: Don’t Wait to Manage Cholesterol

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Controlling cholesterol and lowering your risk of heart disease takes a lifetime. And that’s why newly updated cholesterol treatment guidelines recommend getting an early start on keeping track of your cholesterol numbers.

“Heart disease is a slow process, taking decades to develop,” says cardiologist Mukul Chandra, MD, of Premier Cardiovascular Institute.

Key recommendations of the new guidelines – released by the American Heart Association (AHA) and American College of Cardiology in November 2018 – include:

  • Taking a life-long approach to cholesterol and heart disease management, beginning in your 20s and 30s. And if heart disease runs in your family, start monitoring cholesterol in childhood.
  • Personalizing cholesterol risk assessments and treatment – including use of new cholesterol-lowering drug options if you’re at the highest level of risk 
  • Promoting non-fasting cholesterol tests to make screenings more convenient – to encourage you to be screened and work with your health care provider to lower your risk
  • Using the coronary artery calcium scoring test in certain cases to better determine your heart disease risk level

“These are profound guidelines that affect the life course of millions of people,” Dr. Chandra says. Nearly one in three American adults has high levels of low-density lipoprotein (LDL) cholesterol – a major heart disease risk factor – according to the AHA. Often referred to as “bad” cholesterol, LDL contributes to narrowing of arteries with a buildup of fatty plaques.

Having an LDL level of 100 mg/dL (milligrams per deciliter) or lower tends to decrease heart disease and stroke risk. But the CDC reports that 78 million U.S. adults have LDL levels in the range where cholesterol medicine is recommended – or have other conditions that elevate risk.

“What’s happening is we’re getting more and more people with diabetes in their 20s and 30s. So, diabetes (a major risk factor) is driving our next frontier of heart disease.”

Millennials and Heart Disease

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Heart disease risk is rising for millennials, which is why the new guidelines focus on this generation, Dr. Chandra says. “What’s happening is we’re getting more and more people with diabetes in their 20s and 30s. So, diabetes (a major risk factor) is driving our next frontier of heart disease.”

He adds, “Smoking declined in the ‘70s, ‘80s and ‘90s, and we were having a nice decline in heart disease. Now we have an emergence of diabetes, which is affecting a lot of 30-year-olds.”

The new guidelines advise young adults to track cholesterol numbers and heart disease risk with their health care providers. And children whose families have a history of heart disease can begin testing as early as age 2.

Plus, he says, one in 200 Americans in their 20s have a genetic disorder that can make them vulnerable to high cholesterol levels and raise their chance of “having heart disease when they’re in their 40s. This is why the guidelines are saying that every 20-year-old should know what their cholesterol is.” 

There’s an App for That  

An easy way for millennials and others to track risk for heart disease – and open a discussion with their health care providers – is the ASCVD (atherosclerotic vascular disease) Calculator Plus, a smartphone app (Google Play or App Store), which is also available as a tool on the American College of Cardiology website.

On the ASCVD Calculator Plus you enter your age, sex, race, cholesterol and blood pressure numbers, and medical history. With your health care provider, you can discuss your calculated lifetime risk of heart disease and options for treatment, if needed.

Dr. Mukul Chandra talks about new cholesterol management guidelines and a new app to help millennials and others keep track of their risk of heart disease. Click play to watch the video.

Non-Fasting Test

Getting a blood test for cholesterol is more convenient now. This should encourage more people to learn their cholesterol numbers, Dr. Chandra believes.

“You no longer have to fast before getting tested. No longer do you have to stand in line at 7:30 in the morning to get your cholesterol check done – and then get breakfast. You can go at any time. And it makes very little difference to your numbers.

”A lot of people just don’t make it for a fasting test, because they have to work at 8 o’clock.”

Personalized Risk Assessment

The new guidelines recommend more personalized assessments of your heart disease risk and treatment. Millennials to 45-year-olds should receive a lifetime risk assessment. And if you’re over age 45, you should receive 10-year and lifetime risk assessments.

Dr. Chandra explains that if your doctor finds that your 10-year risk of heart disease is more than 20 percent, you are at high risk of developing heart disease. And if your risk score falls between 7.5 and 20 percent, you are at moderate risk.

If you’re at moderate risk, Dr. Chandra and the new guidelines recommend getting a coronary artery calcium scoring. This low-cost, 10-minute scan, which can be done while you’re clothed, measures the amount of calcium deposits in your arteries. Deposits can indicate the start of plaque buildup that can eventually obstruct blood flow to your heart and lead to a heart attack.

“If your calcium score is above 99,” Dr. Chandra advises, “you should have a conversation with your physician about being put on a cholesterol-lowering medicine to lower your risk for a heart attack or stroke in the future.”

New Treatment Options

The new guidelines also call for new drug treatment options based on your degree of risk and heart disease history.

If you haven’t been diagnosed with heart disease, but have high cholesterol that diet and exercise can’t control, your doctor may recommend that you be put on a statin, a medication to lower LDL cholesterol and your risk of heart disease and stroke.

But if you have high cholesterol and a history of heart disease – and statins aren’t sufficiently lowering your LDL cholesterol – the new guidelines call for prescription of an “add-on” cholesterol-lowering medication, Zetia (ezetimibe), in addition to a statin.

In any case, discuss prescription of cholesterol medication and any part of your care with your health care provider, Dr. Chandra advises.

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