Stricter guidelines on cholesterol numbers still prioritize a heart-healthy lifestyle

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You thought you’d hit the number that meant your “bad” cholesterol was under control. Your doctor gives you a pat on the back – and a new goal.

“Patients may say, ‘Look, I got my LDL to the target I was told to achieve and now you want me to take it lower?’” said Dr. Mehmet Aktas, board member of the Rochester chapter of the American Heart Association. “The response I give to them is that our bodies are changing. Based on our age, our diet and other variables, things change and our goals in terms of what we want to achieve to improve outcomes and reduce heart disease and stroke may change.”

So, too, does the science.

“Evidence now suggests that being a bit more aggressive in lowering the LDL actually will only benefit you,” said Aktas, who also is a cardiologist and arrhythmia specialist at the University of Rochester Medical Center’s Strong Memorial Hospital.

“In the years past, we might think an LDL cholesterol of 130 was good,” he said.

But studies showed that a level of 100 lowered risk even more. And the number keeps going down.

“More recently, evidence has been generated that shows that having an LDL 70 or even lower is beneficial in patients with established heart disease,” he said. “This is really the thing with medicine, we learn over time and we challenge the status quo.”

Cardiologists and primary care providers find themselves explaining to people why the goalposts have moved and the need for a healthy lifestyle, regardless of age or need for medication.

“Cardiovascular disease is the number one killer,” said Dr. Gaurav Sharma, who runs the Lipid Clinic at the Sands-Constellation Heart Institute at Rochester Regional Health. “So, it behooves us to prevent it and then mitigate the morbidity and mortality from it.”

“I tell patients that there are a lot of different disease processes that one could have potentially. This is in my opinion, at this point, a more favorable one to have because we can treat it and we can prevent it.”

In 2018, the American College of Cardiology and the American Heart Association Task Force on Clinical Practice Guidelines updated their guidelines on the management of cholesterol.

The first recommendation is to emphasize a heart-healthy lifestyle for everyone, regardless of the person’s age or need for medication.

Sharma explained that specific recommendations were issued for people between ages 40 and 75, based on their current level of LDL and whether they have diabetes and other risk factors. For some patients, an LDL of 70 mg/dL was used as the threshold to use medications in addition to statins.

Then in 2022, the American College of Cardiology made even more stringent recommendations for people who’d already had a heart attack or stroke.

The ACC also started to provide goals for people who had never had a cardiovascular event and those goals were based on an assessment that factors in age, gender, blood pressure and cholesterol to calculate the 10-year risk of heart attack or stroke. For someone with a risk of less than 5%, the recommendation is to focus on diet and lifestyle, Sharma said.

Cholesterol management and risk mitigation focus on LDL – low-density lipoprotein that can build up in arteries and increase the risk for heart attack or stroke.  “That really is the most important culprit contributing to plaque development,” said Sharma.

Approaches to controlling cholesterol start with lifestyle, whether someone has had a heart attack or stroke or is practicing primary prevention to avoid such an event in the first place. “It’s pretty explicit in all of the guidelines since I was in training,” he said.

Rather than look at what a person can’t eat, Colleen O’Brien, registered dietitian and nutritionist at the Anthony L. Jordan Health Center, looks at what a person can enjoy to be healthy.

“That would be helpful,” she said.

Her recommendations are made in the context of family and culture.

“It’s something I talk about a lot with people. I have to figure out what is something they’re open to doing, that feels comfortable for them. It doesn’t feel like turning their life upside down in terms of what they’ve eaten for 30 years.”

O’Brien said she suggests using healthier oils, decreasing portion sizes, increasing vegetables and trying whole grains such as brown rice instead of white.

“I’ve certainly seen people in tears in my office with the idea that they have to give up certain things or change certain things. Especially if they have a new diabetic diagnosis. It can be very overwhelming. Also, just the emotional connection to food for many people. That’s something we can work through together.”

O’Brien said she believes in the power of small changes. “When I work with patients, I want them to leave feeling comfortable with the decision that we’ve made together.”

“If I just give them a nutrition prescription, I haven’t really helped them if they’re not receptive to doing it.”

Dr. Robert Block leads UR Medicine Cardiac Care’s Clinical Lipidology program. While he prescribes medication, he is a champion of lifestyle changes for their comprehensive effect.

“We know that not only does it lower the risk for heart attack, stroke and blood vessel disease in the lower extremities, but there can be many other benefits.”

He listed reduced risk for diabetes, improved sleep and overall improved quality of life. “If they lose five or 10 pounds, sometimes that makes a difference with blood pressure.”

If lifestyle changes aren’t enough, or if someone has a high risk for a heart attack or stroke, then medication enters the discussion.

Block said patients may hesitate to try a medication for several reasons, including misinformation from social media or other unreliable sources. He said the updated guidelines also provide ways for providers to broach the topic and have a productive conversation.

Block also said newer medications provide cardiologists and patients more choice.

“If someone doesn’t get enough of effect from one type of medication like a statin, or they can’t tolerate the dose or tolerate a statin, there are other medication options which can be very helpful not only by lowering their cholesterol, but also lowering their risk for heart attack and stroke.”

Even if he writes a prescription, Block still dispenses advice about nutrition and activity. “It’s a combination, and this is the way that many of us in this field have been doing this for years.”

Patti Singer is a freelance writer in Rochester. Contact her at [email protected].