From the Guidelines
Statin therapy is recommended for patients with hypercholesterolemia and elevated LDL cholesterol beyond lifestyle modifications.
Treatment Options
- High-intensity statin therapy is recommended for patients with high-risk cardiovascular disease, aiming to reduce LDL-C levels by approximately ≥50% 1.
- Moderate-intensity statin therapy is recommended for patients with moderately high-risk cardiovascular disease, aiming to reduce LDL-C levels by approximately 30% to <50% 1.
- LDL-lowering drug therapy is indicated for patients with LDL-C ≥100 mg/dL, with a goal to achieve an LDL-C level <100 mg/dL 1.
- Combination therapy with a fibrate or nicotinic acid may be considered for patients with high triglycerides or low HDL-C 1.
LDL-C Goals
- High-risk patients: LDL-C goal <100 mg/dL, with a therapeutic option of <70 mg/dL for those at very high risk 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) remain an essential modality in clinical management, with a focus on weight management, physical activity, and dietary changes 1.
- Non-HDL-C is a secondary target of therapy for patients with high triglycerides, with a goal 30 mg/dL higher than the identified LDL-C goal 1.
From the Research
Treatment Options for Hypercholesterolemia
Beyond lifestyle modifications, several treatment options are recommended for hypercholesterolemia with elevated LDL cholesterol. These include:
- Statins: highly effective drugs to decrease plasma concentrations of atherogenic lipoproteins and prevent cardiovascular disease 2
- Ezetimibe: can be added to statin therapy for additional LDL cholesterol lowering 3, 4
- Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors: recommended for add-on therapy with ezetimibe when maximally tolerated statin therapy results in suboptimal LDL-C reduction 3, 4
- Bempedoic acid: can be used in addition to statins and ezetimibe for further LDL cholesterol lowering 3
Treatment Goals
The treatment goals for hypercholesterolemia with elevated LDL cholesterol vary depending on the patient's cardiovascular risk. These include:
- LDL cholesterol level < 55 mg/dl (< 1.4 mmol/l) and at least a 50% reduction from baseline in patients with very high cardiovascular risk 3, 5
- High-intensity statin therapy to lower LDL-cholesterol by at least 50% in patients with cardiovascular disease and those at high cardiovascular risk 2
Additional Considerations
Other considerations in the treatment of hypercholesterolemia with elevated LDL cholesterol include:
- Lifestyle modifications: can significantly reduce triglyceride levels, but play a minor role in LDL cholesterol lowering 3, 5
- Triglyceride-lowering medications: such as fibrates and omega-3 fatty acids, may be used in addition to statins and ezetimibe, but their effectiveness is less clear 3, 5
- New lipid-lowering drugs: are being developed, but their clinical benefits still need to be confirmed in endpoint studies 3, 5