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Don't wait for 5% risk
Medicine 2.0 versus 3.0
That rule belongs to what is called medicine 2.0, which lowers LDL cholesterol once the threshold is crossed. Medicine 3.0 treats the causative agent of a disease whenever there is one. If blood pressure raises the risk of heart disease, blood pressure gets lowered, and if smoking raises risk, smoking gets treated.
How age skews risk
Age is the biggest driver in a 10-year risk model, bar none. A 70-year-old with perfect lipids, perfect blood pressure, and everything else perfect has a 10-year risk of atherosclerotic disease probably four to five times that of the most unhealthy 30-year-old.
A glaucoma comparison
Picture treating glaucoma only once the risk of blindness reaches 5%, a point age alone mostly decides. A 30-year-old would want to learn early if something like sun without sunglasses, or a certain eye drop, did harm.
Outside the United States, ApoB, the count of the particles that drive atherosclerosis, already appears in the guidelines in Europe, Canada, and elsewhere.
Why does age dominate risk calculators?
The 2013 pooled cohort equations from the American College of Cardiology and American Heart Association estimate 10-year risk, and age enters as the largest single input. Arteries accumulate plaque over decades, so over any 10-year window an older person is much closer to an event. The 2018 cholesterol guideline classes a 10-year risk below 5 percent as low, 5 to 7.5 percent as borderline, and 7.5 to 20 percent as intermediate.
Why does lifetime LDL exposure matter?
Mendelian randomization studies use gene variants that lower LDL from birth. A 2017 JAMA analysis led by Brian Ference found that each 1 millimole per liter lower LDL through such variants was associated with about a 54 percent lower risk of coronary heart disease, compared with about 24 percent per millimole per liter in statin trials. The authors attributed the gap to the many years of lower exposure.
Why do some guidelines prefer ApoB over LDL?
The 2019 European Society of Cardiology and European Atherosclerosis Society dyslipidaemia guidelines list ApoB targets alongside LDL cholesterol goals. The Canadian Cardiovascular Society guidelines, updated in 2021, name ApoB and non-HDL cholesterol as acceptable alternatives to LDL cholesterol. ApoB counts particles because each atherogenic particle carries exactly one ApoB protein.
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