New medical guidelines are urging American doctors to begin screening patients for high cholesterol earlier in life.
The 2026 guidelines from the American College of Cardiology and American Heart Association emphasize earlier detection of cholesterol and limiting lifetime exposure to “bad” cholesterol.
“They are making the recommendation to screen people a lot earlier in the U.S.,” said Dr. George Thanassoulis, a professor of medicine at McGill University.
Whereas prior best practice in the U.S. was to recommend screening at age 40, the new guidelines recommend starting screening at 30.
In Canada, by contrast, standard guidance still recommends routine cholesterol screening begin at age 40, except where risk factors warrant earlier testing.
“Cardiovascular disease is a preventable disease,” said Thanassoulis. “For those patients, we recommend screenings start much earlier.”
Shift to ‘lifetime risk’
Diets high in low-density lipoprotein — or LDL — cholesterol can cause fatty deposits to build up in the arteries. Over time, the blood vessels can harden and narrow, until they block blood flow or rupture, leading to a heart attack or stroke.
About half of all Canadian adults suffer from high cholesterol, and the condition is even more common among older Canadians.
There is growing evidence that cardiovascular disease develops gradually over decades, driven by cumulative exposure to harmful cholesterol.
“We need to think about cholesterol as a cholesterol-time-exposure risk factor,” said Thanassoulis. The longer cholesterol circulates in the body, the more it causes long-term damage to the arteries.
“Getting on top of this earlier … is probably the best way to keep populations healthy over time.”
Glen Pearson, a professor of medicine at the University of Alberta and co-chair of Canada’s 2021 cholesterol guidelines, says the shift in the U.S. screening guidance underscores a key difference between the American and Canadian models for assessing cholesterol risk.
The new U.S.-specific screening tool has been adapted to predict the risk of someone having a major health event — such as a heart attack or stroke — 30 years from the screening date.
Canada’s recommended screening tool (the Framingham risk score), by contrast, predicts risks of such events up to 10 years from the screening date. This approach tends to underestimate younger patients’ long-term risk, says Pearson.
“If you estimate the risk for a 40-year-old person, it may be relatively low,” he said. “But we know that lifetime risk is significantly greater than would be predicted at a young age.”
Testing, overtesting
Thanassoulis says Canada may consider changing its screening guidelines when it next reviews them.
“I think the message … has always been that cardiovascular disease is a preventable disease, and the best way to prevent it is to screen patients for their lipids and their other risk factors as early as possible,” he said.
“So I think there’s been a lot of criticism about the fact that Canada recommends screening so late, at 40.”
But expanding routine screening to all adults in their 30s could pose challenges for the health-care system, says Pearson.
“The issue will be the public health consideration,” he said, noting that the costs associated with screening an entirely new cohort of otherwise healthy Canadians may be “problematic.”
Like Thanassoulis, Pearson expects that the issue of screening will be revisited when the Canadian Cardiovascular Society next updates Canada’s cholesterol guidelines, which were last issued in 2021.
Despite the focus on screening and risk prediction, both experts emphasized that the goal of earlier detection is not necessarily to prescribe medication, but to encourage lifestyle changes.
“The first step is always lifestyle,” Thanassoulis said. “We underestimate the impact of lifestyle changes at young ages.”
Screening, he added, should serve as a tool to inform patients about their risk and prompt changes in diet, exercise and overall health.
For now, Canadian clinicians are likely to continue following domestic guidelines while keeping an eye on developments abroad.
“I think there’s increasingly more alignment overall,” Pearson said. “They’re really subtle interpretations of the same evidence.”
