What should I know about the new cholesterol guidelines?

New cholesterol guidelines are helping physicians and their patients take a more proactive — and personalized — approach to cardiovascular risks.
February 4th, 2019

About one in three Americans has high cholesterol. The body needs cholesterol to function normally, but too much of this waxy, fat-like substance builds up in the arteries and may lead to serious problems like heart attack and stroke.

The American College of Cardiology and the American Heart Association recently released new guidelines to help physicians and their patients take a more proactive — and personalized — approach to their cardiovascular risks.

We asked UCHealth heart experts what’s important to understand about these new guidelines. Here are their responses:

First, what is cholesterol?

“There is good cholesterol, called HDL, or high-density lipoprotein. HDL is ‘good’ because it travels through the bloodstream, picks up the bad cholesterol, and delivers it to the liver, where bad cholesterol is removed from the body,” explained Dr. William Cornwell, cardiologist at UCHealth University of Colorado Hospital on the Anschutz Medical Campus.

“Bad cholesterol is called LDL, or low-density lipoprotein. LDL in and of itself is not a bad thing — the body needs cholesterol. The problem is when you get too much of it,” Cornwell said. “LDL travels through the bloodstream and can deposit in the walls of blood vessels. When excess amounts of LDL deposit in the wall, the diameter of the vessel begins to narrow and can prevent an organ from getting the proper amount of oxygenated blood (kind of like kinking a hose).  Eventually, this can cause a heart attack or stroke.”

How do I know what’s happening in my body?

Not enough exercise and too many unhealthy foods make your body produce more LDL, or bad cholesterol. And though some people’s high cholesterol is a result of genetics, unhealthy behaviors are a significant contributors.

Your total blood cholesterol score is calculated by adding your HDL and LDL cholesterol levels, plus 20 percent of your triglyceride level, according to Dr. Patrick Green, a cardiologist at UCHealth in northern Colorado.

A simple blood test called a lipoprotein profile can measure your cholesterol levels. Here is a chart that shows optimal lipid levels for adults, as recommended by the Centers for Disease Control.

Desirable Cholesterol Levels
Total cholesterol Less than 170 mg/dL
Low LDL (“bad”) cholesterol Less than 110 mg/dL
High HDL (“good”) cholesterol 35 mg/dL or higher
Triglycerides Less than 150 mg/dL

Why are the new guidelines important for me to understand?

Although these are desirable levels, the new guidelines take a more individualized approach to cholesterol, according to Dr. Janice Huang, a general cardiologist with UCHealth Memorial Hospital in Colorado Springs.

“Instead of setting a numeric cutoff for cholesterol for initiation of treatment, we are using risk instead,” she said. “For those at highest risk, the push is to get ‘bad’ cholesterol as low as possible, but really the marker is less than 70.”

So, what are those risks?

“We calculate risk using data such as history of hypertension (high blood pressure), age, total cholesterol, HDL cholesterol and smoking,” Huang said.

She recommends that people visit the AHA 2013 risk calculator to understand their risk. The site helps those ages 40 to 75 who have their blood pressure numbers and lipid panel results determine their risk for cardiovascular issues. The new guidelines also acknowledge that patients with chronic kidney disease, women with early menopause or those with a history of pre-eclampsia also tend to be at higher risk.

Talking about your risk with your doctor, however, is still best.

What should I be discussing with my doctor at my next visit?

doctor talking to smiling patient
The new cholesterol guidelines emphasize shared decision-making between the patient and their doctor. Ask your doctor about your risks and your options. Photo by UCHealth.

The new guidelines emphasize shared decision-making between the patient and their doctor, Green said.

“Be prepared to ask questions such as, ‘What is my risk for a heart attack, both short and long term? What are my options if I don’t want to take medication every day? How much does the medicine that is recommended cost? What are possible side effects?  Will this medicine interact with any of the medications I’m currently on?’”

Is there a bigger push to use cholesterol drugs with these guidelines?

According to UCHealth experts, there is not a bigger push for more patients to use cholesterol medications. Rather, the guidelines emphasize the need to identify the correct population of patients who would benefit most from cholesterol medications, and when the best time is for them to start taking the medication. This approach is expected to then minimize the exposure to risk to that lower-risk population.

“If you put together both the cholesterol and exercise guidelines (see related story on exercise guideline changes), in summary, there is a bigger push for lifestyle changes early in life for primary prevention,” Cornwell said.

What are the benefits and risks of cholesterol medications?

Drug therapy is quite effective at reducing levels of cholesterol, according to the experts.

“Statin medication has been shown to be very safe for the overwhelming majority of patients,” Green said. “Some patients report muscle weakness or discomfort (myalgia) that precludes their use. Liver enzymes are typically monitored while taking a statin medication, but risk of liver damage is extremely low.”

Muscle aches or cramps are rare and are usually completely reversed with stopping the statin, Huang added. And though it depends on one’s individual insurance plan, these drugs are the most affordable, as they are the standard treatments for cholesterol, Cornwell said.

PCSK9 inhibitors, a newer class of injectable cholesterol-lowering medications, have been shown to be very safe and tolerated well by the vast majority of patients, Green said. But they are also very costly: $15,000 to $20,000 per year. However, because of demand, Huang said the drug companies are cutting prices by as much as 60 percent. When combined with statins, these inhibitors have shown drastic reduction in LDL levels.

Using a cholesterol-reducing drug may be effective in reducing risk, but it may take time, Cornwell said.

“The effects are not immediate,” he said. “Therefore, for older individuals, whose predicted lifespan is not more than a couple years, a practitioner could reasonably defer treatment because it would expose the individual to risks, like cost and side effects, without any immediate benefit.”

Do age and lifestyle matter when it comes to cholesterol?

Cholesterol levels are important at any age, and that’s why it’s recommended that children start to be tested between the age of 9 and 11, then again between 17 and 21.

“High cholesterol at any age increases lifetime risk of cardiovascular disease,” Green said. “Identifying it and treating and modifying it early can lower that risk.”

In northern Colorado, as part of UCHealth’s Healthy Hearts program, elementary-, middle- and high-school students can participate in the program’s cardiovascular health screenings. The program not only helps identify early heart issues but also empowers and educates students on the importance of heart health even at a young age.

Does family history matter when it comes to cholesterol?

Family history also is a big consideration when determining cardiovascular risks and evaluating cholesterol levels, Cornwell added.

“Family history is more strongly recognized in the new guidelines as a risk factor that needs to be considered, particularly when a patient reports a family history of early heart attacks and strokes in multiple family members,” he said.

For example, if a patient has several family members who all had heart attacks or died suddenly in their 30-40s. This would suggest that this family has a genetic abnormality causing their bad cholesterol to be excessively high.

Why are these guidelines changes happening now?

These guidelines are an update on the 2013 guidelines, which were controversial, Huang said. The 2018 update helps practitioners be more specific in our recommendations and have addressed some gaps left in the 2013 guidelines.

“There has been development of new risk models to help practitioners determine a patient’s risk — importantly, these risk models are more personalized to the actual individual, as opposed to older models that may have been more generalized,” Cornwell said. “Also, there are new drugs available that need to find their place in the guidelines.  The latest set of guidelines helps practitioners understand when and where these drugs should be considered for use.”

About the author

Kati Blocker has always been driven to learn and explore the world around her. And every day, as a writer for UCHealth, Kati meets inspiring people, learns about life-saving technology, and gets to know the amazing people who are saving lives each day. Even better, she gets to share their stories with the world.

As a journalism major at the University of Wyoming, Kati wrote for her college newspaper. She also studied abroad in Swansea, Wales, while simultaneously writing for a Colorado metaphysical newspaper.

After college, Kati was a reporter for the Montrose Daily Press and the Telluride Watch, covering education and health care in rural Colorado, as well as city news and business.

When she's not writing, Kati is creating her own stories with her husband Joel and their two young children.