What’s Different? What’s the Same?
Heart disease isn’t something that develops overnight—it develops over years through a combination of factors. Similarly, the medical community’s understanding of heart disease itself continues to develop. Common wisdom from 20 years ago or even 10 years ago isn’t as specific as what doctors recommend now. (And no, you’re not necessarily bound to end up on cholesterol medication to manage your heart health.)
Risk Factors to Know
In the past, medical understanding of cholesterol came down to how much LDL (“bad” fat) and HDL (“good” fat) you had in your bloodstream. Thanks to medical advances, there’s more to consider if you want the full picture, explains Dr. John Martin, vascular surgeon with University of Maryland Medical Center.
Martin points to the understanding of lipoprotein(a), a genetically determined particle largely independent of diet and lifestyle. Often referred to as Lp(a), it’s now recognized as a causal risk factor for atherosclerotic disease and calcific aortic valve disease, affecting roughly 1.5 billion people worldwide. “Twenty years ago, almost nobody was tested for it; now it’s increasingly part of standard risk assessment, and several RNA-based drugs designed specifically to lower it are in late-stage clinical trials,” Martin says.
He also points to inflammation as a risk factor that’s now understood to be more influential than once thought. Our bodies can suffer chronic inflammation—an immune response to injury or stress—because of obesity, diabetes, poor nutrition, or lack of exercise. “It’s the inflammatory state that actually creates some of the damage to the lining of the vessel that obviously allows the entry of cholesterol into the wall of the vessel,” Martin explains.
Start Early
Your best prevention is early intervention. “Most people don’t start thinking about their heart until, most likely, their 50s, 60s and 70s,” Martin says. “The problem is cholesterol starts in your teens and 20s, particularly if you have genetic problems or family history.”
If you’re at risk, waiting until middle age can be too late. If you know you’re susceptible when you’re in your 20s, you can take preventative measures. “Newer risk calculators, along with tests such as lipoprotein(a) and coronary artery calcium (CAC) scans for some patients, help identify people who may appear healthy today but are quietly accumulating cardiovascular risk over time,” Martin says.
Understanding Statins
You may have heard of statins, the prescription medications that prevent your liver from producing cholesterol. They can help people who can’t bring their cholesterol into a normal range through lifestyle factors alone. But like GLP-1s for weight management, they aren’t miracle workers—adopting healthy habits is most important. “Even promising medications for weight loss or cholesterol work best when paired with lasting lifestyle changes rather than replacing them,” Martin says.
And on that note… Lifestyle Is Most Important. Most of the tried-and-true healthy lifestyle habits you’ve heard before remain the foundation of heart disease prevention. These are practices, Martin emphasizes, we should all be observing regardless of whether you’re susceptible and regardless of whether you’re starting a statin: Focus on a Mediterranean-style eating pattern rich in vegetables, fruits, whole grains, legumes, olive oil, nuts, and fish. Limit ultraprocessed foods, added sugars, excess sodium, and saturated fats. Get regular physical activity. Maintain a healthy weight, avoid tobacco products, get seven to nine hours of sleep, manage stress, and limit alcohol
