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Changing the Conversation about Cholesterol

You know that having high blood cholesterol over a lifetime can increase your risk for heart attack or stroke. So what do the American Heart Association’s new guidelines for managing cholesterol mean for patients with high cholesterol and for those at high risk for heart disease and stroke during their lifetimes?

Sidney C. Smith, Jr., MD, a cardiologist at UNC Medical Center and a member of the committee that drafted the recently released guidelines, explains that the new guidelines are designed to help patients and providers focus on a long-term, lifetime approach to managing cholesterol, preventing heart disease and stroke, and assisting those with known heart disease.

“The guidelines have evolved over time from ‘know your number’ to ‘know your risk’ to ‘personalize your risk,’” says Dr. Smith, a past president of the American Heart Association.

The number Dr. Smith is referring to is the level of LDL cholesterol (low-density lipoprotein cholesterol), or “bad cholesterol,” which contributes to fatty buildup and narrowing of the arteries and results in heart disease. Seventy-one million American adults (33.5 percent) have high levels of LDL cholesterol.

With that reality in mind, the new guidelines instruct providers to work with their patients to calculate their 10-year risk of developing heart disease taking into account cholesterol levels and many other risk factors, including, diabetes, high blood pressure, unhealthy lifestyle and smoking. The risk levels are then defined as low, borderline, intermediate, and high.

To conduct this risk assessment, your physician will ask you a number of questions and score your risk against large population studies. Dr. Smith says your provider may also ask about your “risk-enhancing factors.” Among these are a family history of heart disease or stroke, chronic kidney disease, and inflammatory conditions such rheumatoid arthritis, HIV and psoriasis.

The guidelines also prompt physicians to conduct more advanced screenings for patients at “intermediate risk” for developing heart disease. For patients with risk-enhancing factors who may benefit from lipid-lowering therapy with a statin, Dr. Smith says providers might also recommend a coronary artery calcium scan to get a clearer picture of a patient’s risk. This test can detect if there is any plaque developing on your arteries before you experience signs or symptoms of heart disease.

The guidelines emphasize a “lifetime approach” and strongly advise all patients to talk with their doctor about having their risks assessed and also about the benefits of lifestyle change and medical therapy.

These conversations should start early. If there’s a family history of early heart disease or very high levels of cholesterol, the new guidelines state that it reasonable to measure children’s cholesterol as young as age 2.

Once your risk is established, your provider can develop a personalized treatment plan. For younger patients and patients at low to moderate risk, the guidelines focus on lifestyle changes such as a healthy diet, smoking cessation and exercise.

For those at higher risk but still without heart disease, providers may suggest taking a statin to lower cholesterol.

“If your risk for developing heart disease is above 20 percent, it is well documented that you would benefit from taking a statin, for those with a risk between 7.5 and 20 percent, evaluating the risk-enhancing factors and possibly a coronary artery calcium scan can be helpful in determining appropriate therapy,” Dr. Smith says.

If you are considered an especially high-risk patient, your provider may prescribe other medications in addition to a statin.

Taking these steps to manage your cholesterol levels before they become too high can help reduce your risk of developing heart disease or stroke.

“Overall, we have improved our ability to interpret risk and are emphasizing that patients should be directly involved in working with their physicians to develop a lifelong plan for heart health,” Dr. Smith says.


Talk to your doctor about assessing your risk for heart disease and stroke and about measuring your cholesterol. If you don’t have one, find a doctor near you.