Low‑density lipoprotein is the main driver of plaque formation in coronary arteries and a key determinant of lifetime cardiovascular risk.
The guidelines also lower the LDL target for people at very high risk.
The new guidance also encourages clinicians and patients to take a longer-term view of cardiovascular risk.
Because risk accumulates over time, the longer a person lives with high LDL, the greater their chance of heart disease.
Taken together, the new cholesterol guidelines push prevention earlier, aim lower for those at greatest risk, and expand the tools for assessing long‑term cardiovascular danger.
Cardiovascular disease remains the leading cause of death in the United States, accounting for roughly one in three deaths. Newly updated cholesterol guidelines from the American Heart Association, the American College of Cardiology and nine other professional societies aim to change that by making prevention more aggressive and more personalised, to significantly reduce heart attack and stroke rates. Tamar Polonsky, MD, MSCI, a cardiologist at the University of Chicago Medicine and a co-author of the guidelines, says the overarching message is clear: “The vast majority of cardiovascular disease is preventable.”
The guidelines introduce important changes in screening, risk assessment and cholesterol targets across the lifespan. They emphasise earlier testing, tighter LDL (“bad” cholesterol) goals for people at highest risk, one‑time testing for a powerful inherited risk marker called lipoprotein(a), and a longer-term view of risk using 30‑year projections rather than focusing only on the next decade. They also reinforce that healthy habits remain the foundation of heart health, but that many people will still need medication to reach truly protective cholesterol levels.
One of the most striking changes is how early LDL testing should begin. Low‑density lipoprotein is the main driver of plaque formation in coronary arteries and a key determinant of lifetime cardiovascular risk. The new guidance recommends checking a child’s LDL level around age 10 to identify genetic conditions that cause very high cholesterol from birth and warrant early intervention. Adults should start regular LDL testing at 19, with repeat checks at least every five years, or more often if levels are elevated. “Even people in their twenties can start to develop plaque,” Polonsky notes, underscoring the importance of not waiting until midlife to assess risk.
The guidelines also lower the LDL target for people at very high risk. For individuals who have had a heart attack or stroke and have multiple additional risk factors such as diabetes, hypertension, or smoking or who have experienced more than one heart attack or stroke, the recommended LDL goal is now 55 mg/dL or below, down from 70 mg/dL in the 2018 guidelines. Most people should aim for an LDL under 100 mg/dL, but about one in four adults has a level of 130 mg/dL or higher, putting them in the “borderline high” range. Polonsky stresses that, in the context of cardiovascular risk, lower is better: “There really is no LDL that’s too low when we’re trying to lower a person’s cardiovascular risk.”
Another key update is the recommendation that all adults undergo a one‑time blood test for lipoprotein(a), or Lp(a), a cholesterol‑carrying particle that strongly influences inherited cardiovascular risk. An Lp(a) level above 125 nmol/L signals a higher risk because elevated Lp(a) promotes inflammation and can contribute to clot formation in coronary arteries. Unlike LDL, Lp(a) cannot be lowered through diet or exercise. If high Lp(a) is detected, the guidelines call for a comprehensive risk review including blood pressure, glucose and lifestyle and, in many cases, cholesterol‑lowering medication. Statins do not reduce Lp(a) itself, but they remain the primary treatment because they lower LDL and inflammation, two major drivers of plaque. Polonsky notes that growing evidence links Lp(a) with cardiovascular events and that drugs specifically targeting Lp(a) are now in clinical trials to see if lowering it also cuts heart attack and stroke risk.
The new guidance also encourages clinicians and patients to take a longer-term view of cardiovascular risk. Because risk accumulates over time, the longer a person lives with high LDL, the greater their chance of heart disease. To reflect this, the guidelines endorse a new risk calculator called PREVENT, which estimates both 10‑year and 30‑year risk based on factors such as age, blood pressure, cholesterol and kidney function. PREVENT should be applied from about age 30, helping inform earlier and more tailored decisions about medication and lifestyle. “There are so many other things in our lives, like our education and retirement, where we take a long view and make long‑term investments,” Polonsky says. “We need to do the same with our cholesterol.” Importantly, she emphasises that the goal is not merely to put more people on medicine, but to “better identify who will benefit the most from medication.”
Throughout the guidance, lifestyle remains central. A heart‑healthy diet, regular physical activity and avoidance of tobacco are still the foundation of prevention. For some people, these steps will be enough to bring LDL into a safe range, but many at‑risk individuals will also need medication. Statins are the first‑line drugs and work well for most, yet there are now additional options for those who cannot tolerate statins or whose LDL remains high despite treatment. By contrast, vitamins and supplements should not be relied on for cholesterol control. “I recognize that some people want to use vitamins and other supplements for their overall health, but I want to make it very clear that these supplements are not an effective way to lower LDL,” Polonsky says.
Taken together, the new cholesterol guidelines push prevention earlier, aim lower for those at greatest risk, and expand the tools for assessing long‑term cardiovascular danger. They highlight that most cardiovascular disease can be prevented when LDL is controlled, inherited risk markers like Lp(a) are recognised, and lifestyle and medication are used in combination where needed. For patients, the core message is simple: know your numbers, understand your long-term risk, and work with your care team to protect your heart well before a first event occurs.
