Cholesterol guidelines get a welcome overhaul

Last week, I found myself in a situation that could soon be familiar to a lot more Americans: sliding into a CT scanner with a smattering of electrodes attached to my chest and ribs, my arms raised over my head. A serene voice asked me to take a small breath and hold it. A loudish whirring from the machine, a few shifts of the table, and another request for a small breath later, and suddenly I was sliding back out.

In those two, maybe three minutes, the scanner had collected images of the blood vessels in my heart to look for calcium buildup — snapshots many more people might soon find themselves getting.

Major medical organizations recently updated their cholesterol guidelines for the first time since 2018, taking advantage of tools that offer a longer-term view of heart-attack and stroke risk and allow for earlier preventative care. Practically overnight, that’s changing how physicians approach their patients’ heart health — a welcome development. Cardiovascular disease is still the top killer of Americans, and the new guidelines ideally will motivate more people to make healthy changes.

Let me back up: My cholesterol has been creeping up over the last few years, a situation I suspect is largely related to middle age and my choice of fancy cheese as a pandemic-era vice. My doctor was starting to bring up the S word — statins, prescription drugs that lower so-called "bad" cholesterol and in turn lower stroke and heart-attack risk.

And so, during my recent annual checkup, I found myself having a lengthy conversation with my doctor about heart health. She told me this year she would add a few extra tests in addition to the normal lipid panel, including the coronary artery calcium scan and a simple blood test to measure levels of lipoprotein(a), a particle that ferries cholesterol in the blood.

My visit had serendipitously taken place just weeks after the American College of Cardiology, the American Heart Association, and several other groups put out their new guidelines. Previously, doctors were told to weigh cholesterol levels alongside a long list of other factors — things like diabetes, high blood pressure, smoking and family history of heart disease — to gauge someone’s risk of a heart attack in the next 10 years.

But after a lengthy review of the evidence, they had come up with a more nuanced way of assessing risk — a process they say should start earlier in life. For some, this could lead to earlier treatment, too, with doctors now advocating statins even for some people in their 30s. The updated guidelines also recommend that everyone get their level of Lp(a) tested once in their lifetime. (Because it’s a genetic marker, this doesn’t change much with diet, exercise or even cholesterol-lowering medications, explains Anurag Mehta, a cardiologist at Emory Healthcare.)

The guidelines also suggest that certain people get a coronary calcium scan, a test that can gauge the hardening of the blood vessels. Mehta says this process can start as early as the teenage years for some.

The additional measures can help doctors gauge someone’s chances of having a heart attack or stroke over the next 30 years, not just the next decade. And for doctors, they’re useful "tiebreakers" when a patient’s cholesterol levels are borderline high, explains Roger Blumenthal, the Johns Hopkins Medicine cardiologist who chaired the committee that devised the new guidelines. They can help decide if someone on the edge of needing a statin should start one, and guide doctors in adjusting dosages.

Not everyone will need a calcium CT scan, but clearly there are a lot of people like me out there. My doctor had warned me the wait for an appointment for the coronary calcium test would be long, and indeed, the earliest one I could grab was two months away, quite a hike from my house, and at an ungodly hour in the morning. When I asked the nurse walking me back to the CT machine if they’d been busy, she told me if they hadn’t limited appointments to certain time blocks, they’d be running them "all day, every day."

It’s heartening — pun intended — that physicians are so rapidly adopting the new guidelines.

What’s less encouraging is the lag in insurance coverage for the calcium CT test. Currently, few plans pay for it, and people getting one are likely to find they must shell out money upfront. It’s not wildly expensive — the cost ranges from $50 to $150. Yet that still might put it out of reach for too many people.

Blumenthal believes the strength of the medical groups’ recommendation will change insurers’ attitudes. Let’s hope that happens sooner rather than later.

For my part, the results of those new tests carried some good news. My Lp(a) level is negligible and my calcium CT score was zero — the best possible outcome, as my doctor put it. Between those happy scores and a recent improvement in my cholesterol levels (thanks, weight training!), I was able to put off the statin.

As much as I’d love to celebrate with a wheel of brie, Mehta warned me that a perfect score isn’t a get-out-of-jail-free card. I’ll need to keep up my newfound gym habit and continue to watch what I eat. But I can take comfort knowing that my risk of heart trouble is low — and my doctor is on top of the latest advances to keep it that way.

This column reflects the personal views of the author and does not necessarily reflect the opinion of the editorial board or Bloomberg LP and its owners. Lisa Jarvis is a Bloomberg Opinion columnist covering biotech, health care and the pharmaceutical industry. Previously, she was executive editor of Chemical & Engineering News.