New Cholesterol Targets

We break down the new AHA cholesterol guidelines and why LDL goals are getting lower based on your personal risk. We explain the tests that change the whole picture, including lipoprotein(a), ApoB, and coronary artery calcium scoring, and why women’s reproductive history now counts toward cardiovascular risk. 
• why LDL cholesterol drives plaque buildup and heart attack risk 
• how the 2025 AHA updates replace older LDL targets with risk-based goals 
• using coronary artery calcium scoring to clarify borderline or intermediate risk 
• what lipoprotein(a) is, why it is genetic, and why you must ask for it 
• why pediatric cholesterol testing may start earlier than many expect 
• what ApoB measures and why particle count matters 
• more flexibility beyond statins based on tolerance and preferences 
• pregnancy complications and early menopause as formal cardiovascular risk factors 
Make sure you take this back to your provider and just ask. You can you can just ask.

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Transcript

unknown 0:24

Okay.

New AHA LDL Goals By Risk

Nicole 0:26

Hi everyone. Welcome to another episode of Town House and Telehealth. I'm Nicole Baldwin, Board Certified Nurse Practitioner, and this is my good friend and colleague Kelly White, also Board Certified Nurse Practitioner. And today we're going to talk about the new guidelines from the AHA regarding cholesterol. Now, cholesterol, remember, is what clogs your arteries and causes heart attacks a lot of times, most of the time. Okay. It's like having a drain in the kitchen that is just not draining all the sludge that's built up in the pipes. That's cholesterol. So eventually when you have so much built up and it closes off, that's a heart attack. So cholesterol, high cholesterol equals heart attack. So Kelly, I'll let you take it from here and then we'll chat about it.

Calcium Score Changes The Target

Kelli 1:08

So one of the good things that, or one of the things that I saw come out that I really like. First of all, this is these guidelines are replacing the ones that we had in 2018, I think. And they're demanding a lower LDL. So that's your bad cholesterol. So you've got you've got a couple of different types of cholesterol, right? Like when we look at our patients' panels, we have, you know, good cholesterol, bad cholesterol, triglycerides, you know, all the things. But LDL, this is the target for the LDL. And that's your bad cholesterol, the things that we look at and go, ugh, I don't like that. And so what we're seeing, and what I really like, is now we're we're seeing this shift towards looking at those targets in a in a category. So we're seeing like borderline high, very high risk factors taking into consideration several things about the patient. So, and that's what I like. So we're not just saying everybody's cholesterol should be less than this. Everybody's cholesterol should be less than that. They're taking into consideration the patient's past medical history, past family history. Women, especially, they're taking into consideration their natal history, like if they ever had pre-eclampsia, if they ever had like, and I'm gonna talk about that in a minute, because that's important. And they're taking into consideration their LPA, which I'm gonna let you talk about that here in just a second, because that's a new thing. It's been around for a couple of years, and you and I have tested patients for that, but I want you to hit on what that is and why it is so important. But AHA is finally recognizing that as significant. And I've I've been begging to get my husband's tested. It's very important that patients get this tested, but they finally recognize it for what it is and they're taking that into consideration. Calcium scoring is no longer just an optional add-on. It's now a top recommendation, which is fan-freaking tastic. So they're saying now that, you know, when they put you into these risk categories of, you know, borderline, moderate, and high, that calcium score helps to determine where you fit. So, you know, if you have a calcium score of 100 or plus, then your LDL goes goal should be less than 70. If your calcium score is a thousand or more, then your LDL should be under, say, 55. And so that really pushes patients to have that conversation with their primary care providers, with their cardiologists, whomever you see on a regular basis. And for women, oftentimes that's our gynecologist. I'm gonna be real, we use our gynecologists like we do our primary cares. But if it really pushes you to say, you know, hey, when I get my labs this year, I want an LPA, I want a calcium score, I want to get these tests done because that makes a difference and where you fit. And your history matters. Um, it really does, it really is important as to where you are about that. And so I'm gonna let you real quick, Nicole, if you will, before I jump into the reproductive history of women and why that matters, will you tell our listeners what is LPA? Why does it matter? What is so significant about it?

Nicole 4:17

So the LPA with the A, L A. Yep, little a little P, little, little A, lipoprotein. And that's exactly how it's pronounced, but it is a particle of the cholesterol carrying blood that is genetically inherited. So this having this can raise your risk of cardiovascular disease. So you can be fit as a fiddle, but if you have that type of cholesterol-carrying particle that is genetically inherited, there's nothing that you're gonna do that's going to make that gene go away, but you can help keep your numbers lower. For example, I had a patient one time, he was 32 when I was doing internal internal medicine. He rode his bike to the appointment, fit as a fiddle. Okay. However, his cholesterol was through the roof, through the roof. And I knew looking at him that it was completely genetic because he had no fat on him. He had like he had great cardiovascular strength to be able to ride his bike that far, right? And not be dying. But the the lipoprotein A are mostly determined by genes and are usually fairly stable over a lifetime, but it's almost like an extra particle, like that extra LDL. So LDL is the bad cholesterol. Think of LDL, it should be low. LDL should be low, but it's a it's that extra piece that makes it behave differently than LDL. And so it has its own independent risk factor. And I think Kelly these these just came out, these new guidelines just came out this year, but uh just came out this month. But I think they recommending an LPA at least once in a lifetime.

Kelli 6:12

Okay. At least once. And and I and I think that the the you know they they're pushing that for peach people to get done, you know, as an adult, if you've never had it, even if you don't have a parent with high cholesterol, like you you don't know what their LPA was because that you know, like our parents didn't have that tested. So it's so important, guys, for you to get that tested, even if you walk in and go, My parents are fine, they're healthy. It it doesn't matter. They may not have ever had theirs done. So it's not your standard lipid panel. You have to specifically have ask for this test. It does not come standard.

Why Kids May Need Testing

Nicole 6:46

Yep. It doesn't, it it absolutely doesn't. So you have to, and there's a panel that they can order, and it's called the cardiac IQ panel, and that includes it. Now, it will take a little bit longer to get back from the lab because it does take a little bit longer, but it takes your regular lipid panel if your doctor orders the IQ, and it really gives you that that lipoprotein A, the lipoprote, you know, the alpha lipoprotein B, which we can talk about here shortly, but you really want to get this sooner rather than later. And with the new guidelines, I was reading that they also want you to check the pediatrics between age nine and eleven. Yeah. Yeah, absolutely. For me, that's insane.

Kelli 7:37

Like, I mean, it's I mean, I guess it's good, but for awareness, but I that's crazy to me that we're gonna be, you know, you know, I I think that speaks a lot to, and this is sad, but I think it speaks a lot to America as a whole, because you know, because of our sedentary lifestyles, because of the fast food industries, because of the lack of awareness, I think that we have of cholesterol being such a significant risk factor because LPA is so significant. It's not just your cholesterol, it's that sticky stuff. Like it's it's like if you painted the walls with glue. Everything that touches it is gonna stick. That's your LPA. You have glue on the ends, that's gluey, sticky substance on the inside of your vessels, and you can't get it off. It is there to stay. You were born with it, it lives there, and it increases your risk for things building up, for plaque building up, for blood clots in the arteries, for stuff to happen, for bad things to occur across your lifespan. So knowing that early on, when these guys are little, little, helps us to keep a closer eye on them because gosh, how many times do you open up, you know, articles or you see, heaven forbid, these these high school and college-age kids having massive coronary events.

Nicole 8:58

And they have no collateral, no collateral circulation. If you don't know what that is, you can look it up or you can email us. But they don't have collateral, and so it's often a death sentence.

Kelli 9:08

Yes, it is. Or they have such a life-altering event that they're never, never able to move on with whatever they were doing before, whether that was, you know, they had scholarships to play ball or they were, you know, whatever it was that they were doing, it is life altering all because it wasn't something that they found early on. And again, this is genetic. You're not gonna change it. It is determined by genetics. If one parent has a high LPA, there's a 50% chance that their child is also gonna have a high LPA. So it needs to be checked early, early on. And that is now the recommendation, which I think is is fantastic.

Nicole 9:41

I I think it's important that although you can't change your genetics, that means you really need to be on heightened alert to control what cholesterol you can. Yeah, right. So that doesn't mean, oh, I just I can eat whatever I want because I'm gonna have high cholesterol. No, my guy that was fit as a fiddle with high cholesterol would have probably been huge cardiac events if he wasn't fit as a fiddle because you're adding on top all of these other like things that he can control. So exercise, cardiovascular exercise burns off the cholesterol, except for the genetic one, right? But it burns off everything else. So if you don't have the genetic, you can burn off your cholesterol, right? And that's how we do cardiovascular health.

ApoB And Particle Risk

Kelli 10:27

Yeah.

Statins No Longer First Line

Nicole 10:28

But a quick touch on the on the APOB, it's a blood test that counts how many bad cholesterol particles are in your bloodstream. So the more particles mean the more risk for plaque buildup. So just for some context on how the A and B kind of inter intermingle, if you will. But it is, you know, it is definitely something that if you haven't got done, you really should get done because it really kind of gives you a good indicator. And especially being done young, if someone starts is going to start behind the eight ball with that, it's good to know younger sooner rather than later so that changes can be made, you know, while the parent has a lot of influence over their eating habits.

Kelli 11:12

And I and also want to bring up one of the other great things that they did, they've they've done several with this year's updates to the guidelines. In functional medicine, I talk a lot about healthy cholesterol. And, you know, we try really hard to balance healthy cholesterol against risk factors. That's important. I'm not saying everybody needs a cholesterol, a bad cholesterol under 100. It very much is related to your risk factors because we don't want to starve the person, right? You still need a healthy cholesterol to feed your body. Your body lives off cholesterol. If you didn't need it, you wouldn't have it. It wouldn't even exist. So we still need it. But one of the great things that they've also done in this revamp is they have finally heard what providers like Nicole and I have been shouting from the rooftops that first line is no longer a statin. The first approach, that rigid, got to have a statin first for to lower LDL, gotta have a statin first. Now we have the freedom, they're saying, to choose, which I was anyway, so was Nicole, to choose from multiple therapies based on how much LDL lowering we need and your personal preference. So if you're that person who didn't tolerate statins or you had something else that just wasn't a good fit for you, people like my husband who has had a partial colectomy and they just can't tolerate certain things that work on the bowel. He he is on the um generic form of well call because the there's just certain things that his body just can't tolerate. And so it gives us now the freedom to say they have finally come out and said, okay, we call Uncle, we believe you. Uh, statins don't have to be the first line, right? They know that from a functional standpoint, patients have finally been able to be heard and say, we can work with our diet, our exercise, eating the nutrition and getting the nutrients and the and the you know, vitamins and minerals and things that our body needs to be able to also do this. So therefore, we don't have to just jump straight into the statins that have all these long-term side effects. And so that that was one other great thing that they did. Mm-hmm.

Nicole 13:10

Yeah, absolutely. When I I was telling you earlier before we start to hit the record button that when I started medicine, the good LDL was anything less than 125. Yeah, 125. Anything, anything less, and anything less than that was great and was considered good. And then about 10 years ago, they said, uh, just kidding. Anything less, they're gonna we're gonna tighten it up, right? Anything less than 100 is good, and then you're at risk if it's over. So we're we're getting the numbers getting tighter, which is good because that's gonna be less cardiovascular events, right? Because if if you're, you know, you have a smaller goal, you'll hopefully get get closer to where it's gonna be. So that's good. So then they're saying okay, anything less than a hundred, and now they're saying I was just looking at the wait, hang on, let me pull it back up. We were looking because I wanted to have the guidelines right in front of me because they just changed as of March 13th. Um says the LDL goal should be less than 55 for patients that are at high risk for cardiovascular event.

Kelli 14:13

And those are patients with a high calcium score. So the calcium scores of a thousand or more. So these like these high risk factors. So that and that that was the great thing. Like they finally are taking into consideration the big picture. Finally.

Nicole 14:29

So it should be less than 70 for high risk primary prevention, and then less than 100 for people with uh at borderline or intermediate risk. So they're really breaking it down into different, different levels. It's not just anything below 100 anymore. It's put it's putting you in boxes based on your risk because you can't just put every single patient in the same box and say, oh, if you're under, if you're if you're 99, you're good. Everybody's good. If they're under 99, they're not. And so getting that LPA done is is is really, really good. But you know, it also endorses the selective CAC scoring. So even when, you know, when the statin decisions are uncertain, especially, you know, men and women, intermediate risk, blah, blah, blah, in their 40s, you know, 30s, things like that. So it's super, super important. But primary prevention is key. And, you know, we don't want to wait until, you know, we can etch something in our cholesterol, you know, you know, that we don't want to wait for that invitation. We can get our number sooner, you know, in in the pediatric age and really get a good glimpse. And I've always been a fan of pediatric labs. I think that they I think that we don't run them enough at all. Yeah. I don't think my kid had a full panel until until she was, I mean, of course, at birth and and all the things, but I don't think she had like a full panel blood draw until she was way older.

Women’s Reproductive History As Risk

Advocate For Yourself And Close

Kelli 15:57

Yeah. Even now for women, they're finally starting to include, they've also included your reproductive history, which is another thing that's fantastic. So now we have we I feel like they have finally come full circle. The only thing that now I wish they would take into consideration that they that I didn't see them add, that I wish they would have come across is you know, they they did the APOB, they did the calcium scoring, they even made a little uh comment about incidental CT findings. Uh, they didn't add in men's health, which I kind of wish they would have spent a little time talking about that, because I find that men that fall into that flip side where they have low testosterone, maybe they have a little bit of secondary hapogonalism. I'm like, there's something to be said for those guys. Now, I wonder if they thought that they could put them in a catch-all with catching them with the abnormal calcium scores. So maybe that's they thought that those guys would fall into that risk category anyway. So I'm not sure. I need to research that. I wish they would have spoken to those guys. But I am glad that they finally talked about women because not only does your reproductive history count, but so does your menopausal history. And I'm gonna, I'm gonna hit there for a minute because I counsel women all the time that if you have a family history or you have a personal history of early menopause, that is significant. That is your body letting itself age way too early. So if you have a personal history of pre-eclampsia, gestational diabetes, uh, gestational hypertension, preterm delivery, or early menopause, and that's before the age of 45, you are now formally recognized as a risk factor for cardiovascular disease. And that now counts as part of your cholesterol balance, like where you fall in that risk category. And so that's significant too. So these aren't just pregnancy complications. These, you know, while it happened in the moment, in your later life, this is gonna come into account when we're talking about so it's more of a precursor. Yeah, yeah. So it's gonna count when we start talking about your cholesterol, when we start talking about your long-term health risks. Um, and that is huge in and of itself for me, you know, talking to the women that I talk to and counseling them about, you know, their risk factors going down the road. And that certainly comes into the topic of, and I won't sit here very long because that's not what this is about, but talking to women about being on hormone therapy because those are cardioprotective. So getting women to be on, especially if they're going through early menopause, that perimenopausal stage, putting on putting them on hormone replacement therapy is cardioprotective. And so I think that that's a really, really significant thing to sit on and talk about. So I'm really glad that they included that because that's important moving down the road. Very good. Very, very good.

Nicole 18:40

Well, that is uh, we're gonna close with that today. So thank you all for joining us and we appreciate you taking the time to listen and really learn about your own health, take charge of your own health. Uh, you know, with their such a shortage of providers, of healthcare providers, especially in the more rural areas, and also providers stretch so thin and expected to see, you know, 846 patients in an eight-hour shift, you know, with no lunch and no time to pee. Things, things naturally just fall through the cracks. And so you have to be an advocate for your for your own care. And uh, we thank you very much for uh listening. And make sure you take this back to your provider and just ask. You can you can just ask. So hope you guys have a blessed rest of the day and thank you for joining us. Bye, guys.