Should hypercholesterolemia be treated?

Treatment Decision for Cholesterol 5.72 mmol/L in an Elderly Female

The decision to treat this cholesterol level depends critically on cardiovascular risk stratification—you cannot make a treatment decision based on the cholesterol value alone. 1

Risk Assessment is Mandatory Before Treatment

The total cholesterol of 5.72 mmol/L (approximately 221 mg/dL) falls into a range where treatment decisions must be guided by total cardiovascular disease (CVD) risk, not the cholesterol number itself. 1

You must first determine this patient's cardiovascular risk category:

Very High Risk (LDL-C goal <1.8 mmol/L or <70 mg/dL)

• Documented atherosclerotic cardiovascular disease (ASCVD) 1
• Diabetes with target organ damage or multiple risk factors 1
• Severe chronic kidney disease 1
• SCORE risk ≥10% 1

If very high risk: Treat with high-intensity statin therapy immediately 1

High Risk (LDL-C goal <2.6 mmol/L or <100 mg/dL)

• Diabetes without complications 1
• Moderate chronic kidney disease 1
• SCORE risk 5-10% 1
• Familial hypercholesterolemia without ASCVD 1

If high risk: Treat with statin therapy to achieve LDL-C <2.6 mmol/L 1

Moderate or Low Risk

• SCORE risk <5% 1
• No diabetes, no kidney disease, no documented ASCVD 1

If moderate/low risk: Lifestyle modifications first; consider statin if multiple risk factors present 1

Special Considerations for Elderly Patients

For patients ≥75 years old, the evidence becomes more nuanced. 1

• Moderate-intensity statin may be reasonable if LDL-C is 70-189 mg/dL (1.7-4.8 mmol/L), but this is a weaker recommendation (Class IIb) 1
• Consider stopping statins if functional decline, multimorbidity, frailty, or reduced life expectancy limits potential benefits 1
• The benefit-to-risk ratio shifts with advancing age and comorbidities 1

Critical Missing Information

You cannot answer this question definitively without knowing:

• Does she have established ASCVD? (prior MI, stroke, peripheral artery disease) 1
• Does she have diabetes? 1
• What is her blood pressure? 1
• Does she smoke? 1
• What is her calculated 10-year CVD risk? (using SCORE or equivalent) 1
• What is her functional status and life expectancy? 1
• What is her LDL-cholesterol specifically? (not just total cholesterol) 1

Practical Algorithm

Step 1: Obtain fasting lipid panel to determine LDL-C, HDL-C, and triglycerides 1

Step 2: Calculate 10-year CVD risk using validated risk calculator (SCORE in Europe, pooled cohort equations in US) 1

Step 3: Screen for secondary causes of hypercholesterolemia (hypothyroidism, nephrotic syndrome, medications, liver disease) 2

Step 4: Assess for familial hypercholesterolemia if LDL-C ≥190 mg/dL (≥5 mmol/L) or family history of premature CVD 1, 2

Step 5: Apply risk-based treatment thresholds:

• Very high risk → High-intensity statin immediately 1
• High risk → Statin to achieve LDL-C <2.6 mmol/L 1
• Moderate risk → Lifestyle ± statin based on shared decision-making 1
• Low risk → Lifestyle modifications only 1

Step 6: In elderly patients (≥75 years), weigh benefits against functional status, comorbidities, and life expectancy before initiating therapy 1

Common Pitfalls to Avoid

• Do not treat based on total cholesterol alone—LDL-C is the primary target for screening, diagnosis, and treatment 1
• Do not assume all elderly patients need statins—functional status and life expectancy matter more than age alone 1
• Do not miss familial hypercholesterolemia—if LDL-C is very high (≥190 mg/dL), consider genetic testing and cascade family screening 1, 2
• Do not forget lifestyle modifications—diet, exercise, and smoking cessation are Class I recommendations for all patients regardless of medication decisions 1