From the Guidelines
The optimal level for LDL cholesterol is generally below 55 mg/dL (1.4 mmol/L) for individuals with established atherosclerotic cardiovascular disease or following acute coronary syndromes, with lower targets recommended for those at higher cardiovascular risk. For most adults, an LDL level below 100 mg/dL (2.6 mmol/L) is often recommended, while for individuals with established heart disease or diabetes, an LDL level below 70 mg/dL (1.8 mmol/L) is often recommended. These lower targets are beneficial because LDL cholesterol contributes to plaque buildup in arteries, increasing the risk of heart attacks and strokes. To achieve optimal LDL levels, lifestyle modifications are foundational, including a heart-healthy diet low in saturated fats, regular physical activity, weight management, and avoiding tobacco. If lifestyle changes aren't sufficient, medications like statins (such as atorvastatin or rosuvastatin), ezetimibe, or PCSK9 inhibitors may be prescribed based on individual risk factors and how far the LDL level is from target, as recommended by the International Lipid Expert Panel (ILEP) in 2024 1. Regular cholesterol monitoring is important to assess whether treatment goals are being met and to adjust strategies as needed. Key considerations include:
- Achieving target LDL-C values of < 55 mg/dL (< 1.4 mmol/L) through high-dose statins, or combination therapy with ezetimibe or PCSK9 inhibitors if necessary
- Monitoring and adjusting treatment based on individual response and risk factors
- Emphasizing lifestyle modifications, including a healthy diet, regular physical activity, and control of other atherosclerosis risk factors, such as hypertension, diabetes, and obesity.
From the Research
Optimal LDL Cholesterol Levels
The optimal level of low-density lipoprotein (LDL) cholesterol is a topic of ongoing research and debate. Several studies have investigated the relationship between LDL cholesterol levels and cardiovascular risk.
- A study published in 2019 in the Journal of Geriatric Cardiology found that the optimal LDL level was achieved in 20.3% of patients with established atherosclerotic disease (EAD) or diabetes, and in 46.6% of patients with multiple risk factors (MRF) without diabetes or chronic kidney disease (CKD) 2.
- Another study published in 2022 in BMC Medicine suggested that there may be an optimal target LDL-C level, below which the incidence of cardiovascular events is no longer reduced, and found that this threshold value may be around 70 mg/dL 3.
- A study published in 2023 in Endocrine Connections found that the optimal LDL-C level for preventing cardiovascular disease in patients with type 2 diabetes may vary by age, with an LDL-C level below 55 mg/dL appearing to be optimal in patients under 65 years old, and an LDL-C level of 55-69 mg/dL may be optimal in patients over 65 years old 4.
Factors Influencing Optimal LDL Levels
Several factors can influence the optimal LDL level, including:
- Age: As mentioned earlier, the optimal LDL level may vary by age, with lower levels potentially being more beneficial in younger patients 4.
- Presence of cardiovascular disease: Patients with established cardiovascular disease may require more aggressive LDL lowering, with a target LDL level below 70 mg/dL 3.
- Presence of diabetes or CKD: Patients with diabetes or CKD may require more aggressive LDL lowering, with a target LDL level below 70 mg/dL 2.
Treatment Strategies
Several treatment strategies are available to lower LDL cholesterol levels, including:
- Statins: Statins are a type of cholesterol-lowering medication that can reduce LDL levels by 20-60% 5, 6.
- Ezetimibe: Ezetimibe is a cholesterol absorption inhibitor that can be used in combination with statins to further lower LDL levels 5, 6.
- PCSK9 inhibitors: PCSK9 inhibitors are a type of monoclonal antibody that can be used to lower LDL levels in patients who are not achieving treatment goals with statins and ezetimibe 5, 6.