From the Guidelines
Statin therapy should be initiated in patients over 20 years old when their LDL cholesterol level is 190 mg/dL or higher, regardless of other risk factors. This recommendation is based on the most recent and highest quality study, which prioritizes morbidity, mortality, and quality of life as the outcome 1. The 2019 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol recommends maximally tolerated statin therapy for patients 20 to 75 years of age with an LDL-C level of 190 mg/dL or higher 1.
Key Considerations
- The decision to start statins in patients with LDL levels between 70-189 mg/dL depends on additional cardiovascular risk factors, including diabetes, hypertension, smoking, family history of premature cardiovascular disease, or a calculated 10-year atherosclerotic cardiovascular disease (ASCVD) risk score of 7.5% or higher.
- Common statins include atorvastatin (10-80 mg daily), rosuvastatin (5-40 mg daily), and simvastatin (10-40 mg daily).
- Treatment is typically lifelong, with regular monitoring of lipid levels and liver function tests.
- More recent guidelines, such as the 2025 standards of care in diabetes, also support the use of statin therapy in patients with diabetes and additional ASCVD risk factors, with a goal of reducing LDL cholesterol by ≥50% of baseline and obtaining an LDL cholesterol goal of <70 mg/dL (<1.8 mmol/L) 1.
Additional Recommendations
- For patients with diabetes aged 40–75 years without ASCVD, use moderate-intensity statin therapy in addition to lifestyle therapy 1.
- For patients with diabetes aged 20–39 years with additional ASCVD risk factors, it may be reasonable to initiate statin therapy in addition to lifestyle therapy 1.
- For patients with diabetes at higher cardiovascular risk, including those with one or more additional ASCVD risk factors, high-intensity statin therapy is recommended to reduce LDL cholesterol by ≥50% of baseline and to obtain an LDL cholesterol goal of <70 mg/dL (<1.8 mmol/L) 1.
From the Research
Statin Therapy Initiation
- The decision to initiate statin therapy in a patient over 20 years old depends on their Low-Density Lipoprotein (LDL) level and other risk factors for cardiovascular disease.
- According to the study 2, guidelines recommend statin therapy for adults with severe hypercholesterolemia, defined as an LDL-C level of 190 mg/dL or higher.
- The study 2 found that among younger adults with severe hypercholesterolemia, only 11-20% were on statin therapy, indicating a need for improved guideline-recommended treatment in this age group.
LDL Level Threshold
- The study 2 suggests that statin therapy should be initiated in patients over 20 years old with an LDL level of 190 mg/dL or higher.
- This threshold is based on guidelines that recommend statin therapy for adults with severe hypercholesterolemia, regardless of age.
- Other studies, such as 3, 4, and 5, focus on the efficacy of different statin therapies and combinations in reducing LDL levels, but do not specifically address the threshold for initiating statin therapy in younger adults.
Treatment Options
- The studies 3, 4, 5, and 6 compare the efficacy and safety of different statin therapies and combinations, including rosuvastatin, ezetimibe, and simvastatin.
- These studies suggest that combination therapy with ezetimibe and a statin may be more effective in reducing LDL levels than statin monotherapy, but the choice of treatment should be individualized based on patient characteristics and risk factors.
- The study 6 found that fixed-dose combinations of ezetimibe and rosuvastatin significantly improved lipid profiles in patients with hypercholesterolemia compared with rosuvastatin monotherapy.