The fight against cholesterol and heart disease is escalating and reaching younger generations: The new guidelines of the American Heart Association and the American College of Cardiology, published over the weekend, are changing the rules of the game for millions of people around the world. Instead of waiting for older age or the appearance of initial symptoms, physicians are now called to assess heart health already at age 30, using risk calculators for a three-decade horizon and advanced biomarker blood tests that were not part of routine examinations until now. The main goal of the move is to reduce cumulative exposure to bad cholesterol over decades, based on the understanding that damage accumulating at a young age is the strongest predictor of heart attacks in later stages of life.
Cholesterol is a fatty substance produced in the liver and also found in animal-based foods. It is essential for building cells, hormones, and vitamin D. The problem begins when there is an excess of “bad” LDL cholesterol, which tends to deposit in artery walls and form “plaque” – a fatty layer that narrows blood vessels and disrupts normal blood flow. Unlike many diseases, high cholesterol levels are not painful and are not accompanied by external symptoms, which is why many of them are called “the silent killer.” Without proactive testing and proper treatment, this process can ultimately lead to a complete blockage of the artery, resulting in a heart attack or stroke.
The most significant change in the guidelines is the shift to long-term risk assessment using the new PREVENT calculator, which replaces older equations that focused only on the next ten years. This tool allows physicians to provide patients with a kind of medical “crystal ball,” analyzing data such as body mass index, blood pressure, sugar levels, and smoking habits to predict the condition of a 35-year-old’s arteries when they reach age 65. This approach leads to a dramatic recommendation to begin statin drug treatment already in the 30s for those whose LDL cholesterol level is higher than 160 mg/dL, as experts now determine that waiting until age 50 is often too late, after atherosclerotic plaque has already had time to accumulate in artery walls and cause irreversible damage.
Alongside early treatment, the guidelines introduce two groundbreaking blood tests designed to detect risks that until now remained “under the radar.” The first test is for lipoprotein(a), a type of cholesterol that is genetically determined and is not affected by diet or physical activity, which explains why even people with a healthy lifestyle may suffer sudden heart attacks. The guidelines state that every adult must undergo this test at least once in their lifetime to map their personal risk. The second test, ApoB, provides higher-resolution and more precise measurement of harmful fat particles in the blood, especially for diabetes patients and people suffering from obesity, and allows physicians to tailor drug treatment to the level of personalized medicine.
Perhaps the most surprising news for the general public is the firm stance against the dietary supplement industry, which generates billions of dollars a year. The guidelines explicitly state that popular supplements such as over-the-counter fish oil, turmeric, or red yeast rice are not recommended for lowering cholesterol due to a lack of scientific evidence of their effectiveness. Instead of relying on supplements, experts recommend using advanced imaging technologies such as CT calcium scoring (CAC), which serves as a “tie-breaker” in cases of therapeutic uncertainty. If the test reveals calcium deposits in the arteries, it is conclusive proof that the time for lifestyle management alone is over and that aggressive treatment must begin to prevent the next cardiac event.
The new targets set in the guidelines are the most stringent ever seen in cardiology, with the goal for very high-risk patients dropping to less than 55 milligrams per deciliter of LDL cholesterol. In a world where heart disease remains the leading cause of death, the current revolution seeks to change the medical paradigm: No longer treatment of existing disease, but active and technological prevention that begins decades before the problem emerges. The message to the public is clear: Know your numbers, undergo the new genetic tests, and do not wait for old age to start caring for your heart.
Dr. Itay Gal is a specialist in pediatric medicine, sports and aviation medicine, and a researcher of infectious diseases. He is the health correspondent and medical commentator for Maariv and a lecturer in medicine and innovation.