Target LDL-C Levels in mmol/L for High-Risk Patients
For high-risk patients, the target LDL-C levels should be <1.8 mmol/L (<70 mg/dL), and for very high-risk patients, the target should be <1.4 mmol/L (<55 mg/dL).
Risk Stratification and Corresponding LDL-C Targets
The target LDL-C levels vary based on cardiovascular risk categories:
| Risk Category | LDL-C Target |
|---|---|
| Very high risk | <1.4 mmol/L (<55 mg/dL) with ≥50% reduction from baseline [1,2] |
| High risk | <1.8 mmol/L (<70 mg/dL) with ≥50% reduction from baseline [1,2] |
| Moderate risk | <2.6 mmol/L (<100 mg/dL) [1,2] |
| Low risk | <3.0 mmol/L (<115 mg/dL) [1,2] |
Risk Category Definitions
Very High Risk
- Established atherosclerotic cardiovascular disease (ASCVD)
- Type 2 diabetes with target organ damage or major risk factors
- Severe chronic kidney disease (eGFR <30 mL/min/1.73m²)
- SCORE ≥10% for 10-year risk of fatal CVD 1
High Risk
- Markedly elevated single risk factors (e.g., familial hypercholesterolemia)
- Type 2 diabetes without target organ damage, with duration ≥10 years or with additional risk factors
- Moderate chronic kidney disease (eGFR 30-59 mL/min/1.73m²)
- SCORE ≥5% and <10% for 10-year risk of fatal CVD 1
Special Populations
Patients with Rheumatoid Arthritis
- For 'low-risk RA': LDL-C <3 mmol/L (115 mg/dL)
- For 'high-risk RA': LDL-C <2.6 mmol/L (100 mg/dL)
- For very high-risk RA patients: LDL-C <1.8 mmol/L (70 mg/dL) 1
Type 2 Diabetes
- For T2DM at moderate CV risk: LDL-C <2.6 mmol/L (<100 mg/dL)
- For T2DM at high CV risk: LDL-C <1.8 mmol/L (<70 mg/dL) with ≥50% reduction
- For T2DM at very high CV risk: LDL-C <1.4 mmol/L (<55 mg/dL) with ≥50% reduction 1
Clinical Implications
Research suggests that achieving very low LDL-C levels is both safe and beneficial for cardiovascular outcomes. Studies have shown:
- A 20-25% reduction in CVD mortality and non-fatal MI for every 1.0 mmol/L reduction in LDL-C 2
- No major safety concerns have been identified with LDL-C levels as low as 50-70 mg/dL (1.3-1.8 mmol/L) 3
- Some evidence suggests that levels as low as 20 mg/dL (0.52 mmol/L) may be justified in patients with extensive atherosclerosis where plaque stabilization and regression are necessary 4
Treatment Approach to Achieve Targets
- First-line therapy: Statins at appropriate intensity based on risk category
- Second-line: Add ezetimibe if target not achieved with maximally tolerated statin
- Third-line: Add PCSK9 inhibitors for very high-risk patients not reaching targets with statin plus ezetimibe 1, 2
Monitoring
- Check lipid levels 4-12 weeks after initiating or changing therapy
- Annual monitoring once target levels are achieved 2
- Use non-HDL-C as a secondary target (goal: <2.2 mmol/L for very high-risk; <2.6 mmol/L for high-risk) 1
The evidence strongly supports aggressive LDL-C lowering in high-risk patients, with more intensive targets for those at very high risk of cardiovascular events.