From the Guidelines
Statin therapy is the primary recommended treatment for hypercholesterolemia with elevated LDL cholesterol beyond lifestyle modifications.
Treatment Options
- High-intensity statin therapy is recommended for patients with high-risk or very high-risk profiles, aiming to reduce LDL-C levels by approximately ≥50% 1.
- Moderate-intensity statin therapy is recommended for patients with moderate-risk profiles, aiming to reduce LDL-C levels by approximately 30% to <50% 1.
- LDL-lowering drug therapy should be initiated in high-risk persons with an LDL-C level of ≥100 mg/dL, and consideration should be given to combining a fibrate or nicotinic acid with an LDL-lowering drug if triglycerides are ≥200 mg/dL or HDL-C is <40 mg/dL 1.
- Non-statin therapies, such as ezetimibe, bile acid sequestrants, or niacin, may be considered in patients who cannot tolerate statins or require additional LDL-C lowering 1.
LDL-C Goals
- High-risk patients: LDL-C goal <100 mg/dL, with a therapeutic option of <70 mg/dL for very high-risk patients 1.
- Moderately high-risk patients: LDL-C goal <130 mg/dL, with a therapeutic option of <100 mg/dL 1.
Additional Considerations
- Therapeutic lifestyle changes (TLC), including diet, weight management, and increased physical activity, should be initiated in all patients with hypercholesterolemia, regardless of LDL-C level 1.
- Omega-3 fatty acids may be considered for risk reduction in patients with elevated triglycerides 1.
From the Research
Treatment Options for Hypercholesterolemia
The following treatments are recommended for hypercholesterolemia with elevated LDL cholesterol beyond lifestyle modifications:
- Statins: highly effective drugs to decrease the plasma concentrations of atherogenic lipoproteins and prevent cardiovascular disease 2, 3, 4, 5, 6
- Ezetimibe: can be given to patients who cannot tolerate statins or whose cholesterol level is not adequately lowered 3, 4
- PCSK9 inhibitors: can lower the LDL-cholesterol level by more than 50%, but should only be given to carefully selected patients 3, 4
- Bempedoic acid: can be used in addition to statins and ezetimibe to lower LDL cholesterol 4
Treatment Goals
The treatment goals for hypercholesterolemia with elevated LDL cholesterol are:
- LDL cholesterol level < 70 mg/dL (< 1.8 mmol/L) for patients with very high cardiovascular risk 3
- LDL cholesterol level < 55 mg/dL (< 1.4 mmol/L) and at least a 50% reduction from baseline for patients with established atherosclerotic disease 4, 6
- Reduction of LDL cholesterol by at least 50% in patients with high cardiovascular risk 2
Additional Considerations
- Lifestyle modifications can significantly reduce triglyceride levels and are often more effective than specific triglyceride-lowering medications 3, 4, 6
- New lipid-lowering drugs are being developed for the treatment of patients with severely elevated triglyceride levels and elevated lipoprotein(a) levels, but their clinical benefits still need to be confirmed in endpoint studies 4, 6