Your “normal” cholesterol and blood pressure may no longer be normal

Americans should start preventing heart disease early and aim to lower their cholesterol and blood pressure, according to new guidelines from the nation’s leading medical associations on heart health.

The American Heart Association, American College of Cardiology, and other professional societies released updated cholesterol guidelines in March and blood pressure guidelines in August. Both address important risk factors to prevent heart disease, the leading cause of death in the United States for the past century.

For both cholesterol and blood pressure, the key takeaway is that Americans should aim for lower levels and seek earlier and more aggressive screening and intervention to prevent heart attacks, strokes, and heart failure.

Here are the most important changes experts say and what they mean for your health.

According to new guidelines, everyone should aim for an LDL below 100 mg/dL to prevent heart attacks and strokes. People at higher risk, such as those who have had a previous heart attack or stroke, should aim for less than 70 mg/dL.

People at very high risk of recurrent cardiovascular events (heart attack, stroke, peripheral artery disease) should aim for less than 55 mg/dL, up from the 70 mg/dL recommended by previous guidelines.

The guidelines further specifically state that children can begin getting tested for LDL cholesterol between the ages of 9 and 11.

Both updated guidelines include PREVENT, a new risk calculator that predicts an individual’s risk of developing heart disease or heart failure, taking into account factors such as age, gender, BMI, family history, cholesterol levels, blood pressure, diabetes, kidney function and postal code.

This calculator contains more modern, accurate and comprehensive data than its predecessor, measures risk over longer periods of time (10 and 30 years instead of just 10 years), and is designed to be used starting at age 30 (instead of age 40).

This reflects one of the main themes of the new guidelines: encouraging people to think about their cholesterol early and throughout their lives, not just at a specific point in time, said Dr. Ramzi Dudum, a cardiologist at UCSF.

“This is not so much a big change as it is a renewal of the reality that[plaque formation]is not a process that happens overnight,” he said. “It develops over time.”

The latest guidelines also say people should get tested for lipoprotein(a) at least once in their lifetime, and are worded more clearly than in previous guidelines. Lipoprotein (a) is a type of cholesterol that is determined primarily by genetics and cannot be changed by diet or lifestyle. Elevated levels are associated with increased risk of stroke, coronary artery disease, and aortic valve stenosis. It is determined by a blood test.

Blood pressure guidelines set lower targets than previously, encouraging most adults to aim for blood pressure below 120/80 (lower than 130/80, which was considered normal in the past).

“The lower the better, so that’s the most important point,” said Dr. Joshua Knowles, associate professor of cardiovascular medicine at Stanford University. “And normal blood pressure is lower than we previously thought.”

That means more people are considered to have uncontrolled blood pressure, said Dr. Surabhi Atreya, associate professor of cardiology at UC Davis Health and director of the UC Davis Resistant Hypertension Clinic.

The latest guidelines recommend more aggressive, early and immediate treatment of hypertension. For example, a person with a blood pressure of 140/90 should start dual-drug therapy immediately. Previously, people would start with one drug and add a second drug later. People with blood pressure of 130/80 should receive aggressive treatment if they have other risk factors.

“The main focus is on diet, exercise and lifestyle modification, but if that’s out of control, we start medication a little earlier than we would have done eight to 10 years ago,” Atreya said.

For the first time, the guidelines also take into account GLP-1 drugs, including weight-loss drugs such as Ozempic, which are now much more widely used than they were a few years ago. The guidelines recommend that people who have high blood pressure and are overweight consider prescribing GLP-1.

The guidelines emphasize lifestyle modifications such as yoga and meditation to reduce stress, as well as salt substitutes such as products containing 25% potassium chloride and 75% sodium chloride. Alcohol consumption has also become stricter, with previous guidelines recommending no more than one drink for women and two for men.

High blood pressure and high cholesterol are two of the most common and largely preventable chronic diseases in the United States, affecting nearly half of adults. These are the leading causes of heart attacks, strokes, and heart disease.

Dr. Ankeet Bhatt, a cardiologist at Kaiser Permanente in San Francisco, says that while the population-level prevalence of heart attacks and strokes is decreasing thanks to improved medications and public awareness of risk factors, the incidence of other forms of cardiovascular disease, such as heart failure and deaths from heart failure, is increasing.

“There is some encouraging news, but there is still a lot of work to do,” he said.

The guidelines are intended to help doctors and patients monitor their health and take early action to prevent problems.

Atherosclerosis, the hardening of the arteries that leads to heart disease, can begin earlier in life than many people realize, in their teens. It progresses over time, depending on your genetics, blood pressure, cholesterol, and whether you smoke or have diabetes.

“The goal of these guidelines is to stop this disease if we intervene early,” Knowles said. “An ounce of prevention is worth a pound of cure. The earlier we can treat people who are at high risk throughout their lives, the sooner we can prevent many diseases.”

Professional physician organizations regularly update their guidelines to reflect the latest data and treatments. There are now newer and better drugs to lower cholesterol and blood pressure, and more recent data shows that lower is better.

“We’re kind of in a golden age of lipid-lowering therapy,” Knowles says.

Just 15 years ago, doctors were limited to one type of drug: statins, he said. Since then, there have been effective trials of other types of cholesterol-lowering drugs, including injectables.

“The trials that were conducted to get these drugs approved were very large and very powerful,” Knowles said. “Thanks to them, we now know that achieving lower LDL cholesterol levels has significant risk reduction benefits. We now have evidence to support lower targets than ever before.”

Similarly, new blood pressure targets are the result of recent discoveries that support the benefits of lowering blood pressure. Atreya said there had previously been concerns that 120/80 was too low for older people, but recent trials have found this level to be safe and that tighter blood pressure control can help reduce dementia risk.

“Moderate exercise for at least 30 minutes a day, five days a week, can lower blood pressure in a sustained manner,” says Bhatt. “Blood cholesterol can be lowered by eating a healthy diet and monitoring the glycemic index. For patients who have persistently elevated blood cholesterol or blood pressure, there are effective treatments to lower this.”

Moderate exercise generally means doing it so intensely that it gets your heart rate up and you feel like you can’t hold a conversation with someone, he says.

“Although there is not yet a specific treatment to lower lipoprotein(a), we know that patients with high lipoprotein(a) may benefit from controlling other risk factors,” Knowles said. “That’s the basis for measuring it.”

Lipoprotein(a) is currently not part of the standard lipid panel. It is estimated that only 2% of the population has ever been tested for lipoprotein(a) because it was not previously recommended, Knowles said.

“We hope that now that it’s part of the guidelines, it will be easier to measure and become part of routine care,” he said.

Assess your risk of heart disease using the new PREVENT risk calculator.

“That’s the starting point for talking with your doctor about what you need to do next,” Knowles says.

A CAC test is a scan that checks for calcium deposits in your arteries. This is a marker of plaque buildup and a possible sign that a heart disease process has begun. The test is not new, but the new guidelines recommend it more strongly than the previous guidelines, Atreya said. For example, a calcium score can be helpful if your cholesterol levels are normal but there is calcium in your arteries. This may indicate that they may benefit from lipid-lowering treatment.