New guidelines for treating cardiovascular disease are pushing doctors toward earlier screening and more aggressive treatment, especially when it comes to cholesterol, a major driver of heart attacks and strokes.
Cardiovascular disease remains the No. 1 cause of death in the United States, a title it has held since at least 1950 despite advancements in treatment and screening tools.
Bexar County has a higher heart disease death rate compared to state and national averages, fueled in part by a high prevalence of chronic conditions that raise cardiovascular risk.
“San Antonio has a high prevalence of diabetes, hypertension and kidney disease, including dialysis and peripheral arterial disease,” said Dr. Tzy Shiuan Bruce Kuo, an interventional cardiologist who treats heart attacks and blocked arteries with the Baptist Health System. “All the risk factors for atherosclerotic [and] vascular disease are present.”
Eleven organizations, including the American Heart Association and American College of Cardiology, signed off on the new treatment recommendations, which were last updated in 2018.
Earlier detection, more aggressive cholesterol management
The updated recommendations place a stronger emphasis on detecting high cholesterol sooner, treating it more aggressively, and setting clearer benchmarks for doctors to aim for.
The guidelines are aimed at LDL cholesterol, since higher LDL levels are associated with plaque accumulating in artery walls over time, which may eventually lead to heart attack or stroke.
The goal of the new guidelines is to reduce lifetime exposure to high cholesterol and the plaque buildup in arteries that can quietly follow over several decades, Kuo said.
“You can think of cholesterol like a silent disease that occurs in the background,” Kuo said. “We know that plaque and atherosclerosis occur starting in childhood, and they progress throughout a person’s lifetime.”
Kuo frequently treats patients who arrive after a heart attack or stroke and say they were doing everything right — eating healthy and staying active — only to learn they had severe blockages.
Because plaque can build up slowly and silently for years, Kuo said short-term lifestyle improvements, though vital for managing cholesterol and improving overall health, can give people a false sense of security.
“Just because you’re eating well and exercising … [and] not having any problems for the last couple years, does not mean the disease process is not there,” Kuo said. “The guidelines put a very real emphasis on early detection and aggressive treatment to prevent the disease process that may result in clinical issues decades down the line.”
More screening
The new recommendations reinforce cholesterol screening earlier in life, including during childhood.
For children with a known family history of genetically driven high cholesterol or premature heart disease, screening is recommended around age 9 and again around age 20. In some cases, testing may start as early as 2 years old if there is a strong family history of severe hypercholesterolemia or premature atherosclerotic disease.
The goal is not to put young adults on medication, said Dr. Oscar Rivera, a cardiologist with CHRISTUS Health, but to identify risks early and begin lifestyle changes sooner.
Rivera said early testing can guide diet and exercise interventions and help patients avoid the long-term consequences of cardiovascular disease.
Another shift is in how doctors are encouraged to evaluate patients who fall into an intermediate or borderline risk category, particularly those with LDL cholesterol between 70 and 189.
Doctors are encouraged to refine risk for these patients using additional screening tools, such as coronary artery calcium scoring or advanced lipid testing. Kuo said those tests can help identify patients who appear healthy but may already have plaque buildup or hidden risk.
“This further risk assessment with coronary calcium score, with the enhanced lipid profile — lipoprotein-a and apoB — makes our management of cholesterol more granular,” Kuo said. “That really helps us in the discussion with the patients on whether to start medications or not.”
Clearer LDL targets
The updated recommendations also push for more specific LDL cholesterol targets, especially for high-risk patients. LDL is often the main treatment target because it’s a key contributor to the artery-clogging plaque that drives cardiovascular disease.
“With cholesterol, you can carve out several populations,” Kuo said. “One is the population of patients who already have established disease, who already had strokes, who already had heart attacks, who’ve already had symptomatic peripheral arterial disease, such as blockages in their legs.”
For those high-risk patients, the new guidelines recommend an LDL cholesterol target of less than 55, lower than the previous benchmark of less than 70.
Kuo said the updated recommendations provide clearer direction than past guidance.
“A lot of very clear-cut recommendations are coming out compared to 2018,” Kuo said. “We have specific targets and specific clinical populations that help us determine what to do.”
The guidelines also emphasize follow-up. Doctors are encouraged not only to prescribe cholesterol-lowering drugs such as statins, but to ensure patients are actually reaching target LDL levels. That could mean more patients being prescribed higher-dose statins or additional medications if their cholesterol remains elevated.
Local impacts
The new guidelines could have an outsized impact in San Antonio, where cardiovascular risk factors are widespread. Nearly 17% of Bexar County residents 18 and older have been diagnosed with diabetes — higher than the state average of 14% — according to a 2025 report from the city’s Department of Metropolitan Health.
Kuo said diabetes and kidney disease are heavily emphasized in the updated recommendations.
“The guidelines specifically say that patients with kidney disease and diabetes, even without clinical disease, should be on lipid management,” he said. “That automatically indicates a lot more patients for lipid-lowering therapies. It just really highlights the importance of lipid management. It’s not just an afterthought.”
In practice, that means more primary care doctors and cardiologists will likely have conversations with patients about cholesterol-lowering medications and additional screening tests. It could also mean more follow-up appointments and medication adjustments to hit guideline targets.
Both doctors said the key message is that cardiovascular disease prevention needs to start earlier than many people assume, and that cholesterol is not something most patients can afford to ignore until middle age.
Lifestyle interventions like diet and exercise remain the first line of defense for many patients, but the updated guidelines underscore the importance of knowing cholesterol numbers early, understanding family history and using advanced tools when risk is unclear.
More broadly, the guidelines prioritize prevention over treatment, Rivera said.
“Our goal should be prevention,” he said, “rather than waiting for something to happen to then address it.”
