When should I start thinking about cholesterol and heart health?

You should start thinking about cholesterol and heart health before you have symptoms. High cholesterol usually does not cause symptoms, but over time it can increase the risk of heart attack, stroke and peripheral artery disease.

In Australia, most people should start getting their cholesterol checked from age 45. People with diabetes should usually start from age 35. Aboriginal and Torres Strait Islander people should usually start from age 30, with individual risk factors checked from age 18. You may need to start earlier if you have a strong family history of early heart disease, very high cholesterol, high blood pressure, diabetes, kidney disease, or you smoke.

A cholesterol result is useful, but it is not the whole story. The more useful question is: what is your overall risk of heart attack or stroke, and what can be done to reduce it?

What is cholesterol and why is it important?

Cholesterol is a type of fat in the blood. Your body needs some cholesterol to build cells and make hormones, but too much LDL cholesterol, often called “bad cholesterol” can build up inside of your arteries.[1]

This process is called atherosclerosis. It can narrow or harden arteries and is directly associated with cardiovascular disease, including:

• Heart attack
• Stroke
• Peripheral artery disease
• Coronary artery disease
• Vascular disease affecting the kidneys and other organs

There is also newer evidence linking high LDL cholesterol in midlife with a higher risk of dementia later in life.[2] This does not mean cholesterol medication is prescribed only to prevent dementia, but it is another reason not to ignore your cholesterol.

LDL cholesterol is usually the main treatment target. HDL cholesterol is often called “good cholesterol”, although simply trying to raise HDL with medication has not been shown to be the main solution. Triglycerides can also matter, especially when they are very high or when they occur alongside diabetes, insulin resistance or fatty liver disease.

The point is not to make every number perfect but instead to understand what those numbers mean for your overall risk.

When should I start getting my cholesterol checked?

For most adults without known cardiovascular disease, formal cardiovascular risk assessment is recommended from age 45 to 79.[3,4]

You should usually start earlier if you have diabetes. In that case, formal risk assessment is recommended from age 35.[3,4]

For Aboriginal and Torres Strait Islander people, formal cardiovascular risk assessment is recommended from age 30, with individual risk factors checked from age 18.[3,4]

You should also think about cholesterol and heart health earlier than 45 if you have:

• A parent, sibling or child with early heart disease or stroke
• A family history of very high cholesterol
• A family history of cholesterol that has been difficult to treat
• A known genetic cholesterol condition, such as familial hypercholesterolaemia
• High blood pressure
• Diabetes or pre-diabetes
• Chronic kidney disease
• A history of smoking
• A history of premature menopause
• Inflammatory conditions such as rheumatoid arthritis, lupus or psoriasis
• Severe mental illness

Family history is particularly important when cardiovascular disease happened early. In the Australian guideline, premature cardiovascular disease means coronary heart disease or stroke in a first-degree female relative before age 65, or a first-degree male relative before age 55.[3]

A first-degree relative means a parent, sibling or child.

A father who had a heart attack at 49 is therefore more relevant than a grandfather who developed angina at 84. Both are worth mentioning, but they do not carry the same risk implication.

Does high cholesterol mean I need medication?

No, not just on its own.

High cholesterol matters, but the decision about medication depends on context. Your doctor should usually consider your overall cardiovascular risk, not just one cholesterol result.

That means looking at:

• Your age
• Sex
• Blood pressure
• Smoking status
• Diabetes
• Kidney function
• Cholesterol ratio
• Family history
• Ethnicity
• Atrial fibrillation
• Current medications
• Previous cardiovascular events
• Genetic conditions such as familial hypercholesterolaemia

In Australia, doctors use a risk calculator to estimate your chance of having a cardiovascular event over the next five years. Risk is grouped as low, intermediate or high.[3,4]

• Low risk: less than 5% over five years
• Intermediate risk: 5% to less than 10% over five years
• High risk: 10% or higher over five years

If your risk is high, cholesterol-lowering medication is often recommended unless there is a specific reason not to use it. If your risk is intermediate, the decision is more individual. If your risk is low, medication is often not needed, unless there are other important clinical factors.[3,4]

This is why seeing your GP is useful. Two people can have the same cholesterol result but need different advice because their overall risk is different.

For example, mildly raised cholesterol in a healthy 32-year-old non-smoker with normal blood pressure may be managed very differently from the same cholesterol result in a 62-year-old smoker with diabetes and kidney disease.

Essentially the question to answer is, “Would lowering my cholesterol reduce my chance of heart attack or stroke enough to justify medication?”

What else can be used to determine cardiovascular risk?

Cholesterol is only one part of cardiovascular risk assessment. Other major factors include blood pressure, smoking, diabetes, kidney function, family history, ethnicity, genetic conditions and previous cardiovascular events.

For people with diabetes, extra factors can be included, such as HbA1c, diabetes duration, kidney function, urine albumin, BMI and insulin use.[3]

Some people are already considered high risk without needing the standard calculator. This includes people with known cardiovascular disease, confirmed familial hypercholesterolaemia, or moderate-to-severe chronic kidney disease.[3,4]

There are also “reclassification factors”. These are factors that may move someone’s risk estimate up or down, especially if they are close to a treatment threshold. Australian guidance includes coronary artery calcium score, family history of premature cardiovascular disease, ethnicity, kidney markers and severe mental illness as reclassification factors.[3,4]

This matters because not everyone needs every investigation. A calcium score or lipoprotein(a) should not be ordered just because they sound advanced. The test should answer a practical question and ideally change management.

Lipoprotein(a): the inherited cholesterol marker

Lipoprotein(a), usually written as Lp(a), is a cholesterol-related particle that is largely inherited. That means it can be high even in someone who eats well, exercises and has a healthy weight.

Elevated Lp(a) is an independent and causal risk factor for atherosclerotic cardiovascular disease and calcific aortic valve disease.[5]

Testing Lp(a) can be useful if you have:

• Premature cardiovascular disease
• A strong family history of early heart disease or stroke
• Familial hypercholesterolaemia
• Recurrent cardiovascular events despite treatment
• Unexpectedly high cardiovascular risk
• Intermediate-to-high cardiovascular risk where the result may change management

Australian guidance does not currently recommend universal Lp(a) screening for the whole population.[3,5] It is better thought of as a targeted test in selected people.

The practical issue is that there is not yet a routine primary-care treatment used specifically to lower Lp(a) for prevention in otherwise well people. If Lp(a) is high, the usual response is to manage all other modifiable risk factors more carefully. That means lowering LDL cholesterol, controlling blood pressure, treating diabetes, stopping smoking, improving activity, and addressing kidney disease or other risk factors.

New Lp(a)-lowering therapies are being studied, but they are not yet routine general practice prevention.[5]

Coronary artery calcium score

A coronary artery calcium score, often called a CAC score or calcium score, is a CT scan that measures calcified plaque in the arteries supplying the heart. It does not use dye. It is not the same as a CT coronary angiogram. It is not the right test for investigating chest pain. The main use of a calcium score is to refine risk in selected people who do not have symptoms. It may be worth discussing if:

• Your cardiovascular risk is intermediate
• Your risk is borderline and the decision about medication is unclear
• You have a strong family history of premature heart disease
• Your GP thinks the standard calculator may underestimate your risk
• You are unsure about starting a statin and the result would change the decision

A score of zero means no calcified plaque was detected. That can be reassuring in selected people, although it does not mean “zero risk” and does not rule out soft, non-calcified plaque.[6]

A higher score suggests more calcified plaque and may move someone into a higher risk category. The Australian CVD guideline notes that a score above 99 Agatston units, or a score at or above the 75th percentile for age and sex, may reclassify someone as higher risk.[3]

A calcium score is not recommended for everyone. It is generally not useful if you are already clearly high risk, because treatment would usually be recommended regardless of the result. It is also not generally useful for people at low risk unless there are risk modifiers that suggest the calculator may be underestimating risk.[3,6]

It also has downsides. It involves radiation exposure, although usually low dose. It may find incidental abnormalities that need follow-up. It is not currently Medicare-subsidised. It can create anxiety if the result is unexpected.

The key point: calcium scoring is useful when it changes the decision. It should not be ordered simply because it sounds more advanced than a blood test.

Summary

In short, most people should start formal cardiovascular risk assessment from age 45. People with diabetes should usually start from age 35. Aboriginal and Torres Strait Islander people should usually start from age 30, with risk factors checked from age 18.

You may need to start earlier if you have a strong family history of early heart disease, very high or difficult-to-treat cholesterol, high blood pressure, diabetes, kidney disease, smoking history or a known genetic cholesterol condition.

High cholesterol does not automatically mean you need medication. The decision depends on your overall cardiovascular risk.

Extra tests such as Lp(a) and coronary artery calcium scoring can be useful in selected people, but not everyone needs them. In particular, calcium scoring is usually most useful when risk is uncertain and the result would change management.

If you are in Adelaide and want to understand your cholesterol, blood pressure, family history or heart attack and stroke risk, book a preventive health check or chronic disease review with your GP. Dr Christian Peut provides Heart Health Assessment and chronic disease review at Paradise Medical Centre in Adelaide.

References

1. Healthdirect Australia. Cholesterol: what to do if your cholesterol is too high. Canberra: Healthdirect Australia; 2025.
2. Livingston G, Huntley J, Liu KY, Costafreda SG, Selbæk G, Alladi S, et al. Dementia prevention, intervention, and care: 2024 report of the Lancet standing Commission. Lancet. 2024;404(10452):572-628. doi:10.1016/S0140-6736(24)01296-0.
3. Australian Chronic Disease Prevention Alliance. Australian guideline for assessing and managing cardiovascular disease risk. Canberra: Australian Government Department of Health and Aged Care; 2023.
4. Nelson MR, Banks E, Brown A, Chow CK, Peiris DP, Stocks NP, et al. 2023 Australian guideline for assessing and managing cardiovascular disease risk. Med J Aust. 2024;220(9):482-490. doi:10.5694/mja2.52280.
5. Ward NC, Watts GF, Bishop W, Colquhoun D, Hamilton-Craig C, Hare DL, et al. Australian Atherosclerosis Society position statement on lipoprotein(a): clinical and implementation recommendations. Heart Lung Circ. 2023;32(3):287-296. doi:10.1016/j.hlc.2022.11.015.
6. Jennings GLR, Audehm R, Bishop W, Chow CK, Liaw ST, Liew D, et al. National Heart Foundation of Australia: position statement on coronary artery calcium scoring for the primary prevention of cardiovascular disease in Australia. Med J Aust. 2021;214(9):434-439. doi:10.5694/mja2.51039.
7. The Royal Australian College of General Practitioners. Guidelines for preventive activities in general practice: cardiovascular disease risk. 10th ed. East Melbourne: RACGP; 2024.