Cholesterol levels too high are often only taken seriously when the doctor notices something: if a blood value is out of order. When blood pressure, weight or diabetes are added. Or if there have been heart attacks or strokes in the family. The new recommendations from the American Heart Association (AHA)published in the “Journal of the American College of Cardiology,” make it clear: the risk to the heart and blood vessels often begins much earlier.

cholesterol So it doesn’t just become important after you’re 50. It becomes critical when elevated LDL levels, i.e. the “bad” cholesterol level, go unnoticed for years. The new recommendations therefore look earlier: Who should test young? When are diet and exercise no longer enough? And when do medications become an option? Because there is often a long history behind a heart attack or stroke.

1. Check cholesterol earlier – in childhood and early years

The new recommendations take effect much earlier than many of the previous precautionary measures. Children should receive a cholesterol profile between the ages of 9 and 11. There is primarily a practical reason behind this: This is how familial hypercholesterolemia can be discovered, i.e. a hereditary lipid metabolism disorder with strongly elevated LDL from birth. In the United States, this affects about 1 in 250 people.

After that, the topic shouldn’t disappear again for years. From around the age of 19, a lipid profile is recommended again, and later at least every five years. It becomes particularly relevant for young adults with persistently elevated LDL. If the value is at least 160 mg/dL, i.e. around 4.1 mmol/l, and there is also a strong family history, then treatment should be considered early.

The message behind it is clear: what is important is not just a single laboratory value, but the duration of the stress. Roger Blumenthal, chair of the guideline panel, says in the AHA announcement: “Lower LDL cholesterol over a longer period of time – just like lower blood pressure over a longer period of time – provides significantly better protection against a later heart attack or stroke.” That is the core point of the new guidelines: not to lose years in which the risk grows unnoticed.

2. Recalculate the risk – with a view to 10 and 30 years

What is also important is how personal it is Heart risk will be calculated in the future. For this purpose, the guideline relies on the new PREVENT-ASCVD calculator. It is intended for adults between 30 and 79 years old and is intended to show how high the risk is not only in the next ten but also in the next 30 years. This makes a difference because many vascular problems develop slowly.

• low: less than 3 percent
• borderline: 3 to less than 5 percent
• medium: 5 to less than 10 percent
• high: 10 percent or more

According to the AHA, older risk calculators were often set too high. Blumenthal explains the new approach as follows: “With this new assessment tool, we can better estimate the cardiovascular risk – with the help of health data that is already collected during an annual examination.” This includes cholesterol levels, blood pressure, age and other health data.

What this means in everyday life is that it is no longer just a question of whether something is threatening in the next few years. It’s more about long-term prevention.

3. Lower LDL more consistently – stricter goals apply

For many people, what is particularly important is which LDL values ​​will be the target in the future. LDL is the cholesterol that can build up in blood vessels and narrow them over time. For most people, a value below 100 mg/dL remains the goal. This corresponds to around 2.6 mmol/l. Anyone who is in this range is generally well adjusted to this point.

However, it is much stricter for people at higher risk. Anyone who has a heart risk of at least 10 percent in the next ten years should have an LDL value below 70 mg/dL, i.e. below around 1.8 mmol/l. The target is even lower for people who have already had a cardiovascular disease, such as a heart attack or stroke. A value of less than 55 mg/dL, i.e. around 1.4 mmol/l, applies to them. There is a clear idea behind this: the higher the risk, the more LDL should be reduced in order to better protect the heart and blood vessels.

• most adults: LDL below 100 mg/dL
• high risk: LDL below 70 mg/dL
• after a heart attack, stroke or if you have existing vascular disease: LDL below 55 mg/dL

Pamela Morris, co-chair of the guidelines panel, puts it this way in the AHA announcement: “In general, the lower the LDL, the better – especially for people at increased risk of heart attack or stroke.” There is a simple idea behind this: If you have less LDL in your blood, your blood vessels will receive less material for new deposits.

4. Measure Lp(a) once – a hereditary risk should not be overlooked

What’s also new: All adults should have their lipoprotein(a), or Lp(a) for short, measured at least once. This value is primarily determined genetically and usually remains relatively stable over the course of life. That’s why a one-time determination is often enough.

Lp(a) is not a marginal issue. According to recommendations, around one in five people worldwide has elevated levels. Lp(a) is considered increased from 50 mg/dL or 125 nmol/L. This is associated with a long-term risk of heart attack or stroke that is approximately 1.4 times higher. At 100 mg/dL or 250 nmol/L the risk increases approximately twice.

What is important is that Lp(a) is not significantly reduced through diet or exercise like LDL. The measurement therefore primarily serves to classify personal risk more precisely. Anyone who is abnormal here often needs stricter control of the other risk factors – especially LDL. The guidelines therefore do not assess Lp(a) as an isolated problem, but rather as a serious warning signal.

5. Don’t overestimate dietary supplements – the guidelines clearly advise against them

Another part of the recommendations is particularly close to everyday life. Many people initially rely on gentle alternatives from drugstores or pharmacies. Fish oil, garlic, turmeric, cinnamon, plant sterols or red rice sound harmless and sensible. However, the new guidelines are clear here: dietary supplements are not recommended to lower LDL or triglycerides.

The justification is based on concrete data. A recent study compared a low-dose statin, an LDL cholesterol-lowering drug, with a placebo and six commonly used dietary supplements. The statin reduced the LDL value by around 35 percent. None of the tested agents were able to measurably reduce LDL levels compared to placebo.

There is also a second point: dietary supplements are significantly less strictly regulated than prescription medications. Requirements for effectiveness, safety and manufacturing quality are lower. “Many patients are skeptical about prescription medications, but often have a whole range of unproven preparations at home,” says Blumenthal. The guidelines take a clear stance on this: If you want to effectively reduce your risk, you need reliable data – and not just a good feeling when you reach for the shelf.

The bottom line is that the new cholesterol recommendations make one thing clear above all: prevention begins earlier, risk assessment becomes more precise, LDL targets become stricter and additional hereditary risks such as Lp(a) should no longer remain in the dark. This is not a special topic for cardiologists. It affects many people long before the first serious warning sign appears.

Briefly summarized:

• High cholesterol levels should be detected earlier: in children, and later regularly in young adults.
• What is important today is not just individual values, but also personal long-term risk and stricter LDL goals.
• A one-off Lp(a) test for adults is also new, while dietary supplements are not a reliable solution for cholesterol, according to recommendations.

By Anne Bajrica