Breaking Down Cholesterol: Understanding New 2026 Guidelines and What They Mean for Your Heart

Welcome back to Cardiovascular Therapeutics Unplugged! In this episode, our hosts dive deep into the world of cholesterol a number everyone talks about, but few truly understand. With new guidelines released on cholesterol management, Dr. Aditya Mehra breaks down what these updates actually mean for patients and clinicians. From demystifying LDL, HDL, and lipoprotein (a), to clarifying the real significance of your cholesterol numbers, they explore why early and ongoing screening is more crucial than ever. You'll hear about the latest in statin therapy, innovative medications like PCSK9 inhibitors, the importance of the "prevent" risk calculations, and practical strategies for both lifestyle and medical management of cholesterol. Whether you’ve just had a blood test or want to understand how to protect your heart for the long haul, this episode has the answers you need with real, jargon-free conversation that empowers you to take charge of your cardiovascular health.

00:00 Understanding cholesterol basics

03:37 Understanding cholesterol levels

07:49 Understanding cardiovascular risk guidelines update

13:01 Understanding lipid profile risk markers

16:11 Understanding 2026 screening guidelines

19:15 Discussing heart-healthy diets

21:25 Using lipid-lowering medications

27:04 Cholesterol-lowering drugs discussion

28:09 Cholesterol-lowering drug options

31:15 Understanding 2026 cholesterol guidelines

34:52 Calcium scoring and LDL therapy guidance

Transcript

SPEAKER_01 0:00

One of the things to understand is that atherosclerosis doesn't begin at 60 or 70. It begins very early in life and it progresses slowly over decades. To treat that, you have to understand that identifying risk early on is more important in treatment so that you've not missed the boat when you start treating your cholesterol at 60. You can change your parents, but you can modify your genetic risk by treating earlier, screening earlier, and then treating for a longer period of time. If you're South Asian, you're at a higher risk, so make sure that you understand your risk profile and your numbers, including your lipid profile. Screen earlier, check regularly, aim for a lower LDL level, and treat longer.

SPEAKER_00 1:04

Many people are told they have high cholesterol, handed a prescription, or warned about a heart attack risk, but few actually really understand what those numbers mean or how treatment decisions are made. Recently, new guidelines have changed how doctors think about cholesterol treatment, from sad ins and combination therapy to newer medications designed to lower risk even further. So, what do those updates actually mean for patients? Welcome back to Cardiovascular Therapeutics Unplugged, real conversations about heart treatments that change lives. I'm so excited to see you again, Dr. Mera, and have this conversation. I know everyone hears about cholesterol all the time, but like I said, it's definitely misunderstood. So I'm excited to see you and dive into this episode. But how are you doing today?

SPEAKER_01 1:44

I'm great. Good to see you again. It's been a while. I know this one's been a little delayed, but I've been wanting to talk about these new cholesterol guidelines for the last couple of weeks since they came out.

SPEAKER_00 1:54

Absolutely. And I love that it is recent and we're going to be talking about it and life happens. So I'm sure all the listeners are happy to hear from you now. And yeah, let's hop in. So speaking about cholesterol, so when patients hear that their cholesterol is high, what's the most common misunderstanding about what it actually means for them and for their heart risk?

SPEAKER_01 2:14

There is a lot to talk about cholesterol. It's it's it's one of the things that you know cardiologists get questioned about, deal with on a regular basis. It's part of our daily practice. So whenever there's a guideline update, there's a whole new excitement about the education aspect of it for the physicians, the providers, as well as for the patients. So let's start with understanding what cholesterol is and why is it important. So, you know, as as you know, my podcast is more about breaking things down to the basics and not keeping it too filled with medical jargon. So let's understand what cholesterol is first, and then we can dive into the guidelines and its management and what's changed with the new guidelines. So, cholesterol, the molecule itself, the substance itself is a waxy, fat-like substance that is essential to the cell membranes and the basic construction of the hormones in our body, the bile acids, the vitamins that are made. It is a substance that is produced by the liver, but also we we get it from dietary sources like meats and egg and dairy. It contributes widely to physiological functions, it regulates cell membrane permeability, it enables cell signaling across special microchannels and microdomains, it helps in the build, it it is a building block for glucocorticoids, mineral corticoids, these are all these different hormones that we have in our body and contributes to metabolic, reproductive, and and and bone health. So it is a very, very essential component of our body. But when it is elevated to a certain extent where it gets deposited in the blood vessels of our of our body, then it can start causing some harm. It can it can affect our circulation. So that's when cardiologists get concerned about it, that we've got too much total cholesterol and its components that are probably not just helping with the building and essential functioning of the body, but now it's starting to cause harm. So it is important to have a measurement on a regular basis on every patient that is that is at risk. Get diving further into it, the types of cholesterol that at least the general population should understand is that there's bad cholesterol, which is LDL cholesterol, low density lithol protein, that carries about 60 to 70 percent of our plasma or blood cholesterol, and that is the main contributor to our arterial plaque formation. So we want in general the levels to be less than 100 milligrams per deciliter. And if somebody's got LDL over 190, that's when we start getting concerned as doctors. Good cholesterol, it's HDL, which you'll see on your blood work, high density lipoprotein, it's about 20 to 30 percent of our plasma cholesterol. And this is important. The higher this is, the better it is for you. It removes the excess cholesterol from tissues and it it helps the liver excrete the excess cholesterol. So we want HDL to be as high as possible. Ideally, you know, over 60, but 40 is great. Over 40 is great. Anything less than 40, you start thinking that you're you're at a higher cardiovascular risk of events. And then there's other cholesterols, very low density lipoprotein and triglycerides that also contribute to plaque formation and atherosclerosis. So cholesterol metabolism is quite complex, but bottom line is to understand the low density lipoprotein is what we look at for bad cholesterol. HDL is what we look at for the protective effect of good cholesterol, and then there's the non-HDL cholesterol, which gives us an estimate of certain things like apolipoprotein B, lipoprotein litl A, which has become more important as a risk marker and also a marker of cumulative and genetic risk that somebody has. So those are the things that have been highlighted a lot more in the new guidelines.

SPEAKER_00 6:27

So and those metrics and numbers you mentioned are so good to know because, for example, I just got my blood work done pretty recently and I didn't know exactly what was good, what was bad. So having those markers or indications are super helpful for especially the average patient. And you did mention the new dyslipidemia guidelines were recently released. So, in simple terms, what actually changed and why are cardiologists paying so much attention to it?

SPEAKER_01 6:53

Yeah, so let's again understand why these things are important. So the last set of guidelines was in 2017, and we've, you know, we've been looking at what is important to look at in patients and what is what are the most important kind of things to predict, the cumulative lifetime risk of cardiovascular events, what are the most important things to measure? So there's constant reassessment that happens by the various societies as more and more data comes through. In the last set of guidelines till now, we were not looking at certain components and we had essentially removed clear-cut numbers and we were ascribing percentage risks based on risk factors, but the numbers had gone away. Now that those numbers are back, clear-cut guidelines so that it's easier for practitioners to aim for certain goals. That's been an important change. But in any case, to understand the changes, you have to understand the lifetime burden of cholesterol exposure is a critical determinant of your atherosclerotic cardiovascular risk. One of the things to understand is that atherosclerosis doesn't begin at 60 or 70. It begins very early in life and it progresses slowly over decades till it starts to manifest itself clinically. So that happens over years. And to treat that, you have to understand that identifying risk early on is more important, and treatment then becomes more important early on, so that you've not missed the boat when you start treating your cholesterol at 60. So that's one of the most important things to understand. Based on that, the guidelines have been redefined now. The risk assessment and treatment thresholds for the new guidelines have come up with certain tools which are easier for practitioners to follow. The guidelines now recommend, for example, the PREVENT equations, P-R-E-V-E-N-T, prevent equations, instead of the older pooled kind of cohort equations for 10 and 30 year risks. The PREVENT stands for predicting risk of cardiovascular disease events. So that's the new tools. And within that, the CPR model guides the clinical, the decision making. This gives us a patient's 10-year cardiovascular risk and it personalizes the risk estimate for the patient. So CPR here, the CPR model stands for calculating the 10-year risk, personalizing the risk, and then reclassifying using the corneary artery calcium score. This has been something that, you know, as people have heard about the corneal artery calcium, that has been incorporated into the new guidelines as well. So like I mentioned earlier, the return of the treatment goals has been a major shift in the 2026 guidelines, becoming more specific about the LDL and not non-HDL level treatment goals.

SPEAKER_00 9:51

Absolutely. And speaking about that, and even going back to what I touched on earlier, being a patient and not always understanding all the medical jargon and things like that, patients often focus on total cholesterol or LDL numbers. It was seems a little bit more familiar, but which numbers actually matter the most on cardiologists assess cardiovascular risk?

SPEAKER_01 10:12

So, like I said, so some of the things to understand, let's look at, for example, primary prevention. If somebody is a borderline or intermediate risk, an LDL goal, bad cholesterol goal of 100 to remember easily is important. A non-HDL or non-good cholesterol goal of 130 is good. So somebody at borderline or intermediate risk, 100 and 130. Those are the two numbers to remember. For high risk primary prevention, you want the bad cholesterol to be less than 70 and the non-HDL cholesterol to be 100. So that's that's primary prevention in high risk patients. Now, people who've had a cardiovascular event, who've had a heart attack or a stroke, you want to drive that bad cholesterol down to 55. Those are the key LDL levels less than 55 and non-HDL levels less than 85. Those are basically the numbers to remember. There's certain risk markers that I just alluded to earlier, certain risk markers that have been emphasized a lot more in these guidelines are the lipoprotein little A. People have heard about it. It's the new fashionable thing that everybody wants measured in their lipid profile. If your lipoprotein little A is greater than 125, then that is associated with an increased risk of a cardiovascular event. If it's greater than 250 nanomoles per liter or 100 milligrams per deciliter, you have a twofold higher risk of a cardiovascular event. So elevated lipoprotein little A, again, it should be measured at least once in all adults. It is something that doesn't change. That's like a genetic risk marker. But if that's elevated, that tells you that you need to focus more aggressively on driving down that LDL, that bad cholesterol. So measuring lipoprotein littl A is important. And the next one that's an emerging risk marker has been apolipoprotein B. This again is important for guiding therapy and risk assessment. And the apolipoprotein, just as a side note, is more important patients who have diabetes and elevated triglycerides.

SPEAKER_00 12:23

And speaking about driving down that number, that LDL number, many people believe diet and exercise alone should really control cholesterol. But at what point does cholesterol become a therapeutic problem rather than just a lifestyle issue?

SPEAKER_01 12:38

So one more thing that I wanted to say about the 2026 guidelines was the bottom line message that there are four things, four aspects to these guidelines that are important to understand going forward. You want to screen earlier, like I mentioned. You want to check regularly, not just check at 60 or 70. You want to screen earlier, depending on your risk factors. Some people need to be screened for familial hypocholesterolemia based on their family history and their teenage years or, you know, as adolescents or children. You want to check regularly. You want to screen people at the age of 19 if necessary, once they're past their childhood. After 18, if they're at high risk from a genetic standpoint, you want to screen them earlier. You want to aim for a lower LDL, like I said, if somebody's got familial hypocholesterolemia or other risk factors. And then you want to treat longer with a medication that modifies that risk. As we know, there's certain modifiable risk factors and certain risk factors that are non-modifiable. And your genetics are non-modifiable, but you can change your parents, but you can modify your genetic risk by treating earlier, screening earlier, and then treating for a longer period of time. So that's that's one of the take-home messages of the CPR model, calculating the risk earlier and then reclassifying, personalizing the estimated risk and treatment uh regimen.

SPEAKER_00 14:06

Absolutely. And like you said, you can't change your parents. There's only so many things you can control. And when people think about controlling their cholesterol, I think most people tend to really believe that diet and exercise alone should control cholesterol. But at what point does cholesterol become a therapeutic problem rather than just a lifestyle issue?

SPEAKER_01 14:24

Yeah, so you know, we encounter this on a regular basis in our practice. People are hesitant to take medication. Some of the drugs have had bad, you know, press because of the internet or whatever, or misconceptions or ideas that are just prevailing out there. Drugs do have some side effects that sometimes, you know, the patients are not able to be compliant with those medications. But there are two aspects. I mean, it's not just about throwing medication at patients. One of the things, like you said, diet and exercise. That is an important part, and that's stressed once again in the guidelines. You want to have a good plan to emphasize dietary patterns in patients with dyslipidemia. So you wanna, the American College of Cardiology and the American Heart Association have clear dietary guidelines which emphasize the intake of fruits and vegetables, nuts and legumes and whole grains and fibers while replacing saturated fats and trans fats with dietary monounsaturated fats and polyunsaturated fats. And the idea again being to decrease the LDL levels and modifying the atherosclerotic cardiovascular risk over the next 10 years, 20 years. So there are multiple diets, but the idea is always to replace the saturated fat, increase fruits, vegetables, nuts, legumes in your diet. And overall that leads to integration with your medical regimen to modify risk. Some of the diets that are worth mentioning that people have definitely heard of if they have high cholesterol, a Mediterranean diet, which is, you know, we know that people in the Mediterranean, this comes from the areas of Italy and Greece and the Mediterranean countries that, you know, supplementing what I mentioned earlier with extravagant oil or nuts and fruits and vegetables decreases cardiovascular events. This was shown in what's called the pre-med trial in high-risk individuals for primary prevention of heart disease. And then there's the DASH diet, which is, you know, the diet has shown to improve hypertension outcomes and cardiovascular outcomes in patients. So it's always important not just to throw medication, actually sit down and discuss these nutritional guidelines with patients so that they can incorporate that into their day-to-day life. Now, having said that, when you don't reach your goals and there's, you know, there's obstacles to your optimal LDL goals and non-HDL goals, that's when medications come in. And there's a variety of lipid lowering medications that are there for optimal treatment of cardiovascular risk. A number of the cardiovascular outcome trials have shown their safety, their tolerability, their efficacy over the years. So statins are the most common ones. They have been the foundation of cardiovascular risk reduction and dyslipidemia treatment for many, many years. They remain the first-line therapy both for primary prevention of heart disease and for secondary prevention. We have patients who've had heart attacks and have stents placed in their heart. We do secondary prevention with high-intensity statins to drive down their LDLs, like I said, based on these guidelines, to less than 55. And there's these high-intensity statins have shown in multiple trials to decrease from the year risk of cardiovascular events. So, for example, a torvostatin of 40 to 80 milligrams is considered high intensity, or resuvastatin, 20 to milligrams, 20 to 40 milligrams is considered high intensity. And these drugs typically reduce your LDL by greater than 50%. So the cardiovascular event reduction is well documented in multiple trials. Now there's other medications to consider. Some non-statin medications have come up to treat, to be adjunct to statins or to treat other things, other components of dyslipidemia like high triglycerides level. The triglyceride lowering medications like fibrates and niacin have been considered, but they have not had very, very strong evidence as much as statins.

SPEAKER_00 18:35

Speaking about statins, I know that they have been around for decades, but they are still one of the most important tools in cardiovascular prevention. So it's interesting that they still play such a central role in treatment. And in more recent years, we've seen newer medications like PCSK9 inhibitors and other therapies. So how do these fit into treatments today and who actually really needs them?

SPEAKER_01 18:58

Yeah, so like I said, like I alluded to earlier, statins are still the cornerstone therapy. We've got years and decades of data now. And it was once again, after reviewing all the data, they were once again reinforced a lot in the new guidelines. So we have to remember that. But they do have possible side effects, intolerability, muscle aches, elevation, and liver enzymes could happen. So then there's other medications that can be used to kind of help with treatment of dystopidemia. One of the medications is zetomybe, which is an intestinal cholesterol absorption blocker. It reduces LDL cholesterol by about 18% or so in trials. The improve it trial, improve-it trial, was a landmark trial that showed that adding zetomide to statin therapy in people who've had heart attacks reduced cardiovascular events. So it was a good study with good outcomes that showed that this drug helps us. And there are certain new drugs that came out a few years ago, the ones that you just asked about, PCS canine inhibitors. These were a major advancement in lipid lowering therapy. And they're essentially monoclonal antibodies that are injectables, and they're injected just like insulin is injected subcutaneously. And there are two of them that are available on the market. The most common name, you know, if people have heard, you might have seen commercials on television, Praluent, and then RAPATH. These drugs reduce LDL levels by as much as 50 to 60% and have demonstrated very, very strong reduction in cardiovascular events as a result in a couple of landmark trials, such as the four-year trial and the Odyssey outcomes trial. More so for physicians who are listening, but the data has been very, very strong for these drugs. There's been extended safety data with these drugs now for almost 10 years. So these drugs have been an option, although injectable, but they're injected every two weeks in general. They've been a great option for patients who are not able to tolerate statins for whatever reason. There's another drug, enclysceran, that is available that it's a class of drugs, which is uh interesting, small interfering RNA-based PCS canine inhibitor, which is again, it's injectable. It has to be given by healthcare professionals and again showed drastic reductions in LDL cholesterol. So that's been the class of PCS canine inhibitors. There's a new drug that has been around for a little bit. The bempadoic acid or nexatol, it's been around. Again, it's an oral drug that has shown efficacy in reducing LDL by 20 to 25%. And that's been a good option as well. Some of the other drugs that are available bile acid sequestrants, these have been around for a while. They do more so, again, they bind bile acids in the gut and they help reduce in cholesterol. From by about 10 to 20 percent. So what we have to remember is that once you've identified the risk in these patients, especially that you need to really be aware of that was stressed in these guidelines were people with familial hypercholesterolemia, there's diabetes, and there's chronic kidney disease patients. One of the other populations that was talked about in these guidelines is the South Asian population. They're at high risk of cardiovascular events, and understanding that driving down LDL to low levels for this population is really, really vital.

SPEAKER_00 22:34

Absolutely. And speaking about medications, I think it's common for a lot of patients to really worry about taking long-term medication, especially or particularly cholesterol medication. So how do you help patients weigh the risks of medication versus the risks of untreated cholesterol?

SPEAKER_01 22:50

Yeah, just stressing this again, understanding that this is again, I believe in a shared decision-making approach. I tell patients, listen, these are the guidelines that have come out. This is the research. In the end, it is their body, their health. I'm here to make recommendations based on the best available evidence that we have in science. And as a practitioner, as a scientist, as a doctor, my emphasis and my what I give importance to is staying on top of the latest information that is out there that I can share with my patients. So I tell them, listen, I understand these are the side effects, these are the advantages, ask the questions that need to be answered so we can come up with a shared treatment strategy. The 2026 guidelines, bottom line is emphasize that your lifetime exposure to elevated cholesterol, elevated as a consequence, throgenetic lipoproteins increases your risk of a heart attack, stroke, and all other cardiovascular events, including cardiovascular mortality. So it's important to identify early and treat longer if necessary. And then that counseling goes further in discussing their health behavior, their risk reduction, such as smoking cessation, they're including their dietary counseling. We want to start that early on, especially in people like I mentioned in their childhood years, basically, if they have familial hypercholesterolemia. So that is what the new guidelines suggest. Monitoring, explaining to patients that it's not just throw a drug and forget about it. Monitoring their liver enzymes, for example, and their lipid profiles on a regular basis every month to three months becomes important to see how they're doing with the medication. Is there any escalation or de-escalation needed in the medication dosages? So when you explain these things to patients, I think they're more amenable to understanding their risk as well as taking the medication if needed.

SPEAKER_00 24:39

Absolutely. And I think guided approach is super helpful. And before we wrap up this episode, is there anything else that you wanted to add, Dr. Mara?

SPEAKER_01 24:47

I wanted to address the top take-home messages of the guidelines. And screen earlier, check regularly, aim for a lower LDL level, and treat longer. That's been stressed in these guidelines. Trade take-home messages is reduce the cardiovascular risk, do the prevent calculation, use the prevent equation to estimate people's cardiovascular risk. You can find the prevent equation online. It just puts in people's different kinds of risk factors into the equation to calculate their 10-year risk. And then based on that, you can assess their LDL goals, calculate the take-home messages, test for apolipoprotein A and Apolipoprotein B to improve their risk assessment and guide therapy. Check for lipoprotein little A at least once to identify individuals that are at higher risk of cardiovascular risk. I mentioned corneary artery calcium scoring that needs to be done, you know, men at least at 40 and women at 45 years of age to improve again risk assessment and guide LDL therapy. Both the absolute amount of calcium artery score is important, corneal artery calcium is important, and the corresponding standardized percentile have prognostic significance. So that's important. What else? In patients who have persistently elevated triglycerides, start with statin therapy and then you can add other medications as needed. And that's an important kind of guideline update as well. So these are the take-home messages that I wanted to mention. Oh, last one more that if you're South Asian, you're at a higher risk. So make sure that you understand your risk profile and your numbers, including your lipid profile.

SPEAKER_00 26:19

Absolutely. Cholesterol isn't just a lab number, it's one of the most important drivers of long-term cardiovascular risk. So understanding what the numbers mean, when treatment makes sense, and how guidelines evolve can really make a real difference in protecting your heart. Thank you so much, Dr. Mara, for really helping us make sense of these new recommendations and always providing such valuable information. And thank you for all the listeners. This has been another great episode of Cardiovascular Therapeutics Unplugged. Real conversations about heart treatments that change lives. Make sure if this resonated with you, that you share, subscribe, and continue to follow the show. And it's a pleasure as always to speak with you, Dr. Marin. I can't wait to talk to you soon.

SPEAKER_01 26:58

Thanks, Layla. It's been a pleasure. Look forward to the next episode. And hopefully, people understand the importance of uh checking out their lipids and understanding their risk profile.

SPEAKER_00 27:09

Absolutely. Thank you. Take care.

SPEAKER_01 27:11

Take care. Bye.