New cholesterol guidelines urge Americans to act earlier on ‘bad’ cholesterol and other blood fats to lower lifelong heart attack and stroke risk. Here's what you need to know

High cholesterol is often treated as a number on a blood test, but new US guidance is urging doctors and patients to look at the bigger picture. The latest recommendations place greater emphasis on identifying and treating unhealthy blood fats earlier, with the goal of reducing a person’s lifelong risk of heart attack, stroke and other cardiovascular problems.

About one in four adults in the US is estimated to have high LDL cholesterol, often called “bad” cholesterol. When LDL and other harmful lipids remain elevated over time, they can contribute to plaque buildup in the arteries, a condition known as atherosclerosis.

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New cholesterol guidelines take a broader approach

The updated guidance replaces the previous cholesterol recommendations issued in 2018. Rather than focusing only on LDL cholesterol, the new approach also considers other lipids and lipoproteins that can contribute to dyslipidemia and atherosclerotic cardiovascular disease (ASCVD).

"We know 80 percent or more of cardiovascular disease is preventable and elevated LDL cholesterol, sometimes referred to as 'bad' cholesterol, is a major part of that risk," says cardiologist Roger Blumenthal from the Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, the chair of the guideline writing committee.

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The central message is simple: addressing cholesterol earlier may offer greater protection over a lifetime.

"While we want to try to optimize healthy lifestyle habits as the first step to lower cholesterol, we realize that if lipid numbers aren't within the desirable range after a period of lifestyle optimization, we should consider adding lipid-lowering medication earlier than we would have considered 10 years ago."

Cholesterol screening could begin in childhood

One notable change is the recommendation for cholesterol screening to begin between ages 9 and 11 if a child has not previously been screened.

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Testing can happen even earlier, from age 2, when there is a family history of serious cardiovascular or cholesterol-related disease.

The updated recommendations also introduce greater use of the PREVENT calculator for adults aged 30 to 79. The tool estimates a person's 10-year and 30-year cardiovascular disease risk using information such as cholesterol levels, blood pressure, age and health habits.

"With this new assessment tool, we can better estimate cardiovascular risk using health information already obtained during an annual physical – cholesterol, blood pressure readings, and other personal information such as age and health habits – and then further personalize the risk score for each individual by looking at 'risk enhancers', which can help guide the need for lipid-lowering therapy," Blumenthal says.

Lower LDL cholesterol may offer greater protection

The guidelines bring back specific LDL cholesterol targets to help guide treatment. LDL-C goals are less than 100 mg/dL for people at borderline or intermediate risk, less than 70 mg/dL for those at high risk and less than 55 mg/dL for people with ASCVD who are considered very high risk.

"In general, lower LDL is better, especially for people at increased risk for a heart attack or stroke," says cardiologist Pamela B. Morris from the Medical University of South Carolina.

Statins remain the primary medications used to lower LDL cholesterol, while other options include ezetimibe, bempedoic acid, PCSK9 inhibitors and inclisiran.

Lifestyle changes still matter

Despite the increased focus on earlier treatment, the new cholesterol guidelines continue to emphasize healthy eating, physical activity and other lifestyle changes.

For people whose cholesterol remains elevated despite making healthier choices, doctors may now consider medication sooner based on their overall cardiovascular risk.

The broader message is that cholesterol management is not simply about reacting to a high number. Regular screening, early action and keeping harmful cholesterol levels lower for longer could help reduce the risk of heart attack and stroke later in life.