Management of High Cholesterol

Risk Assessment and Treatment Goals

The American Family Physician recommends beginning with therapeutic lifestyle changes immediately for all patients, and initiating statin therapy simultaneously if the patient has coronary heart disease or CHD risk equivalent, with LDL-C ≥100 mg/dL 1, 2
The American Family Physician suggests calculating the patient's 10-year CHD risk using Framingham risk scoring, which requires total cholesterol, HDL cholesterol, blood pressure, smoking status, and age 1, 2
For high-risk patients, the LDL-C goal is <100 mg/dL, and the Non-HDL-C goal is <130 mg/dL, which is 30 mg/dL higher than the LDL-C target 1, 2, 3, 4
The American College of Cardiology recommends initiating statin therapy at LDL-C ≥130 mg/dL for high-risk patients, with drug therapy optional at LDL-C 100-129 mg/dL 1, 2

The American Heart Association recommends reducing saturated fat to <7% of total calories, and limiting cholesterol intake to <200 mg/day in high-risk patients 5, 3
The American Heart Association suggests eliminating trans fatty acids, and replacing saturated fats with monounsaturated fats and polyunsaturated fats 5, 1
The American College of Sports Medicine recommends prescribing 30-60 minutes of moderate-intensity aerobic exercise most days of the week, which raises HDL-C by 5-14% while lowering triglycerides by 4-18% 6
The National Institutes of Health recommends targeting BMI between 18.5-24.9 kg/m², and waist circumference <35 inches in women 5

The American College of Cardiology recommends statins as the drug of choice for elevated LDL-C, and should be initiated preferentially in high-risk patients 5
The National Lipid Association suggests that statins reduce LDL-C, total mortality, and coronary artery disease events 5
The American Heart Association recommends atorvastatin 10-80 mg daily, which reduces major cardiovascular events by 37% at 10 mg in diabetic patients, and by an additional 22% when escalated to 80 mg versus 10 mg in patients with established CHD 5
The American College of Cardiology recommends checking liver function and creatine kinase levels when initiating statin therapy, and reassessing lipid panel 4-12 weeks after starting treatment 7

The American Diabetes Association recommends that when triglycerides are ≥200 mg/dL, non-HDL-C becomes a secondary treatment target after achieving LDL-C goals 3, 4
The National Lipid Association suggests that non-HDL-C represents all atherogenic cholesterol, and is an independent predictor of cardiovascular events 3, 4
The American Heart Association recommends calculating non-HDL-C as total cholesterol minus HDL-C, and targeting non-HDL-C 30 mg/dL higher than the corresponding LDL-C target for each risk category 3, 4

The American College of Cardiology recommends considering adding fibrates or niacin after achieving LDL-C goals, if non-HDL-C remains elevated or HDL-C remains low (<40 mg/dL in men, <50 mg/dL in women) 5, 6
The National Lipid Association suggests that fibrates increase HDL-C by 15-25%, and are most effective for combined low HDL and high triglycerides 6
The American Heart Association recommends fenofibrate as first-line for triglycerides >200 mg/dL with low HDL-C, and warns that combining statins with fibrates increases myositis risk 7