Transcription
The 2026 cholesterol guidelines just came out, and here are my big takeaways. Right off the bat, we're having to move away from the 10-year pooled cohort equation and to move towards the PREVENT equation. The PREVENT equation was studied in 30 to 79-year-olds, so it's more inclusive, and it's also more precise and more accurate.
With the new risk calculator, we have a new reclassification of risk. We still have low, borderline, intermediate, and high-risk patients, but those thresholds change. It's never happened to me before that already I'm doing something and then the guidelines come and confirm it, but I'm happy to see that everyone should be getting at least one screening lipoprotein A level. And the guidelines also give us better clarity on what to do with apolipoprotein B, which is also a risk enhancer. And both apoB and lipoprotein A are highly potent atherogenic particles, so the lower the better.
What I found interesting is that we can even use it as a secondary target in patients for secondary prevention who have already had a heart attack or stroke to mitigate some of their residual risk. For very high-risk patients, we can target an apoB less than 55, and for those secondary prevention patients who are not very high-risk, apoB less than 70. And there's other evidence in the guidelines that indicate we can use apoB as a secondary marker for both primary and secondary prevention. For instance, in patients with a calcium score greater than 1,000, we want to get their LDL less than 55, their non-HDL less than 85, and then you can also use an optional apoB target of less than 55. Again, to help mitigate their residual risk.
These guidelines also expanded the risk enhancers. Many reproductive risk markers for women, inflammatory conditions like lupus, rheumatoid arthritis, advanced psoriasis, inflammatory arthritis. And I'm happy to see greater guidance on treating younger patients because I always felt that a 30-year-old with very high cholesterol, the only difference between them turning 60 is 30 years of exposure of that compounding interest of that plaque building up in their arteries over time.
Overall, when we're discussing these new changes to our patients, there's going to be someone who came in last week and didn't require medication and now, based on their new classification, might benefit from one. I think it's up to us as clinicians to have that discussion one-on-one with our patients to explain that high cholesterol plus these inflammatory conditions can help propagate or worsen atherosclerosis. None of these conditions happen in isolation, and our number one piece of advice for every patient is still going to be healthy diet, low saturated fat, exercise regularly, don't smoke because overall it is the cumulative risk and exposure over time. The longer one of these conditions is uncontrolled, the higher your future risk is going to be.
And I love these new cardiovascular disease society guidelines, but I also want to see those same cardiovascular disease societies going out into the communities and educating the general public. An ounce of prevention is worth a pound of treatment, and the same thing is true for education and combating misinformation.