In a 68-year-old woman with total cholesterol 198 mg/dL, triglycerides 65 mg/dL, HDL‑C 86 mg/dL, LDL‑C 102 mg/dL, and non‑HDL‑C 112 mg/dL, what is the recommended management?

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Last updated: October 5, 2026 • View editorial policy

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Management Recommendation

This 68-year-old woman with LDL-C 102 mg/dL, HDL-C 86 mg/dL, triglycerides 65 mg/dL, and non-HDL-C 112 mg/dL does not require statin therapy based on these lipid values alone, but requires cardiovascular risk assessment to determine if treatment is indicated.

Risk Stratification Required

The decision to initiate lipid-lowering therapy depends entirely on her 10-year atherosclerotic cardiovascular disease (ASCVD) risk, which cannot be determined from lipid values alone 1. You must:

  • Calculate 10-year ASCVD risk using the pooled cohort equations (requires age, blood pressure, smoking status, diabetes status)
  • Assess for clinical ASCVD (prior MI, stroke, peripheral arterial disease, coronary revascularization)
  • Check for diabetes mellitus (automatically elevates risk category)
  • Evaluate for risk-enhancing factors if risk is borderline (5-7.5%) or intermediate (7.5-20%)

Lipid Analysis

Her current lipid profile is actually quite favorable:

  • LDL-C 102 mg/dL: Slightly above optimal (<100 mg/dL) but not markedly elevated 2, 1
  • HDL-C 86 mg/dL: Excellent (goal >50 mg/dL in women) 2 - this is protective
  • Triglycerides 65 mg/dL: Optimal (<150 mg/dL) 2
  • Non-HDL-C 112 mg/dL: Near optimal (<130 mg/dL for most risk categories) 2

Treatment Algorithm Based on Risk Category

If She Has Clinical ASCVD (Secondary Prevention)

  • Start high-intensity statin immediately regardless of baseline LDL-C 1
  • Target LDL-C <70 mg/dL (she's currently at 102 mg/dL) 3, 1
  • If very high-risk ASCVD (multiple events or one event plus multiple high-risk conditions), target LDL-C <55 mg/dL 3

If She Has Diabetes Without ASCVD

  • Start moderate-intensity statin without calculating risk 1
  • Consider high-intensity statin given age >50 years 1
  • Target LDL-C <100 mg/dL 4

If Primary Prevention (No ASCVD, No Diabetes)

10-year ASCVD risk ≥20% (high risk):

  • Start moderate-to-high-intensity statin 1
  • Target LDL-C <100 mg/dL 2

10-year ASCVD risk 7.5-20% (intermediate risk):

  • Have clinician-patient risk discussion 1
  • Consider statin therapy, especially if risk-enhancing factors present 1
  • Risk-enhancing factors include: family history of premature ASCVD, chronic kidney disease (eGFR 15-59), metabolic syndrome, premature menopause, inflammatory diseases 3

10-year ASCVD risk 5-7.5% (borderline risk):

  • Emphasize lifestyle modification 1
  • Consider statin only if risk-enhancing factors present 1

10-year ASCVD risk <5% (low risk):

  • No statin indicated - focus on lifestyle 1
  • Her excellent HDL-C (86 mg/dL) and low triglycerides suggest she may fall into this category if other risk factors are absent

Lifestyle Recommendations (Universal)

Regardless of whether medication is started 1:

  • Maintain heart-healthy diet: <7% saturated fat, <200 mg/dL cholesterol 2
  • Regular physical activity: minimum 30 minutes most days 5
  • Maintain healthy weight (BMI 18.5-24.9 kg/m²) 2
  • Avoid tobacco 2

Critical Pitfall to Avoid

Do not automatically start a statin based solely on LDL-C 102 mg/dL in a primary prevention patient. The 2018 AHA/ACC guidelines moved away from treating to specific LDL-C targets in primary prevention and instead emphasize risk-based treatment decisions 1. Her favorable HDL-C and triglyceride levels suggest lower cardiovascular risk, and many women with this profile and no other risk factors would have <7.5% 10-year risk, making statin therapy optional rather than mandatory.

Next Steps

  1. Obtain missing clinical information: blood pressure, smoking status, diabetes status, family history
  2. Calculate 10-year ASCVD risk using pooled cohort equations
  3. Screen for clinical ASCVD if not already done
  4. Have risk discussion with patient about benefits/risks of statin therapy based on her calculated risk
  5. Consider coronary artery calcium score if risk is intermediate and decision remains uncertain 3

References

2
Guideline

evidence-based guidelines for cardiovascular disease prevention in women: 2007 update.

Journal of the American College of Cardiology, 2007

4
Guideline

american association of clinical endocrinology clinical practice guideline: developing a diabetes mellitus comprehensive care plan-2022 update.

Endocrine practice : official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologist, 2022

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