When we go for an annual physical or see a cardiologist, most of us think we know what to expect: a cholesterol check, a blood pressure reading, an EKG, and a reminder to exercise and eat well. But preventive cardiology is evolving rapidly, with more tools than ever to spot risks early so we can act years before symptoms appear.

This spring, major medical groups released updated 2026 guidelines on what they call the management of “dyslipidemia,” an umbrella term for a range of issues including high cholesterol, elevated lipoprotein(a) or Lp(a), high triglycerides, low HDL, and high LDL. While many experts welcomed the changes, they noted they still fall far short of the latest science. “The new guidelines are better than the 2018 guidelines, no question about it, but they’re still lagging behind,” says Dr. Jaime Burkle, a top preventive cardiologist and Chair of Cardiology at the Atria Health Institute. In fact, they’re based on reviews of studies published over the last 5-10 years, and those studies typically use data from the previous 3-5 years, Burkle explains, so the guidelines are based on data that is as much as 10 years old. 

During that time, physicians like Dr. Burkle and others who focus on preventive medicine have advanced to more aggressively managing metrics beyond cholesterol, screening much earlier to detect risk for more people, and personalizing treatments based on individuals’ health histories. 

Here’s how to think about your own heart risk—and how a more proactive approach can catch trouble years before symptoms appear.

Focusing on numbers beyond cholesterol

Historically, the emphasis on heart health has been on cholesterol, with a focus on LDL, the so-called “bad” cholesterol. However, experts now know that LDL alone doesn’t capture your full risk. Here are two other markers that deserve more attention than they typically get: 

  1. Apo-B: This counts the total number of harmful particles in your blood. LDL is the best known of these, but apo-B predicts cardiovascular risk more accurately. “While LDL is one specific model of truck carrying cholesterol in your bloodstream, apo-B is the license plate on every type of dangerous vehicle threatening your arteries,” says Dr. Burkle. This matters because apo-B can be high even when LDL looks healthy, making it a risk factor that a basic panel would miss. If you have an elevated apo-B, your physician may recommend statins or other lipid-lowering therapies along with lifestyle changes.
  2. Lp(a) is a cholesterol-carrying particle in your blood that is almost entirely genetically determined. Up to 20% of people have elevated Lp(a) levels, yet very few are tested for it because it’s not on a standard lipid panel. “It’s like a fuel accelerant for atherosclerosis,” says Dr. Burkle, who treats a high level as roughly a 1.5 times risk factor—on par with smoking or diabetes. Today, no drugs directly target Lp(a) yet, but knowing your level can inform the rest of your care. For example, if your Lp(a) is high, your doctor may take a more aggressive approach to cardiac prevention; this might not move the needle on that one metric, but it can reduce your overall risk of heart disease. Encouragingly, new drugs to target Lp(a) are in late-stage development, some of which Dr. Burkle is a principal investigator on.

For more on specific heart health stats worth tracking, see this article on our site: Heart Health Stats You Should Know. 

Early detection is key

This is where Atria’s perspective diverges most from standard practice. Conventional care leans heavily on risk calculators: you enter your numbers, a 10-year risk estimate comes out, and a low score often means “come back in a year.” The trouble, Dr. Burkle says, is that many patients walk out with plaque in their arteries without even realizing it, because the calculator underestimated their risk and more proactive imaging and testing isn’t considered.

The new American Heart Association PREVENT™ Online Calculator is a useful starting point (toggle to the right-hand tab to see the tool). But rather than predicting risk from a formula alone, preventive cardiologists like Dr. Burkle look for “subclinical atherosclerosis,” the plaque buildup in arteries before symptoms appear. Using a coronary CT angiogram and ultrasound of the carotid, aorta, and leg arteries, physicians can assess how much plaque a person has and where it sits—and they do this screening at younger ages than the guidelines recommend.

Some people have a genetic condition called familial hypercholesterolemia, for example, which causes dangerously high levels of LDL cholesterol from birth. It makes them six times more likely to develop heart disease than the general population, but very few pediatricians screen for this so it’s often undiagnosed until someone’s first heart attack. The new guidelines recommend screening at ages 9-12, which Dr. Burkle says he hopes will encourage more physicians to screen young people and teach those at risk about the importance of prevention.

The guidelines also advise using coronary calcium scores mainly for patients who are at intermediate risk of heart attack or stroke. Atria’s view is that waiting until plaque has hardened means missing the window when intervention matters most. A calcium score above zero means calcified plaque, and that means soft plaque has been accumulating for years. “When a patient comes to us with a calcium score above zero, we’re already late,” Dr. Burkle says.

There’s even more nuance for women because their plaque calcification tends to happen later than in men, so a calcium score can read zero even when soft plaque is present. Studies show that soft plaques often contain a lipid-rich core and inflammatory cells. This makes them more unstable and more likely to rupture, which can trigger a blood clot leading to a heart attack or a stroke. Calcified plaques are generally harder and more stable, although they still reflect underlying atherosclerosis and cardiovascular risk. To assess soft plaque, the most modern cardiologists will use coronary CT angiography (CCTA), often with an artificial intelligence overlay. Since research shows that women face heart attack risk at lower plaque levels than men, if plaque does show up, that’s a sign to act. 

Personalized treatment

This kind of personalized screening is key. A common misconception is that everyone should aim for the same cholesterol number. Your ideal lipid management depends on what’s happening inside your arteries—your plaque, your health and family history, and your other labs.

That’s why Atria sets targets individually, and often lower than the guidelines. For someone with established plaque, the goal isn’t simply an LDL below 70, but below 55. The reasoning is encouraging: research suggests that below 70 you stop new plaque from forming, but below 55, some existing soft plaque can dissolve and go away. Keeping arteries as clean as possible not only helps prevent heart attacks and strokes, but also protects against the small-vessel damage linked to dementia in later life. In fact, high LDL cholesterol accounts for roughly 7% of dementia cases worldwide, meaning that if everyone successfully managed their LDL cholesterol starting in midlife, about seven out of every 100 cases of the disease could be entirely prevented. 

The bottom line

The most powerful thing you can do is know your numbers—and the right numbers. Ask your physician about apo-B and Lp(a), not just total cholesterol, HDL, and LDL. If your Lp(a) is high, medications are in the works, and in the meantime, don’t “add wood to the fire,” in Dr. Burkle’s words. Don’t smoke, keep your weight and blood pressure in healthy ranges, and stay active. For younger patients, Dr. Burkle points to benign supplements like L-carnitine or coenzyme Q10 (CoQ10), which trials suggest can modestly lower levels.

We have more ways than ever to detect cardiovascular disease early and act on it. The future of heart health isn’t a single number on a lab report. It’s a clear, personalized picture of your arteries, captured early enough to change the story.