How should a patient with a cholesterol level of 228 mg/dL, triglycerides of 336 mg/dL, LDL of 138 mg/dL, and a ratio of 5.4 be managed?

Management of Elevated Cholesterol and Triglycerides

Immediate Treatment Recommendation

You need to start statin therapy immediately to address your elevated LDL cholesterol (138 mg/dL) and triglycerides (336 mg/dL), combined with aggressive lifestyle modifications targeting weight loss, elimination of added sugars and alcohol, and restriction of saturated fats. 1

Understanding Your Lipid Profile

Your lipid panel reveals moderate hypertriglyceridemia (336 mg/dL) combined with elevated LDL cholesterol (138 mg/dL), which significantly increases your cardiovascular disease risk. 1

• Calculate your non-HDL cholesterol (total cholesterol minus HDL cholesterol) with a target goal of <130 mg/dL, as this secondary lipid target becomes important when triglycerides are 200-499 mg/dL. 1
• Your triglyceride level of 336 mg/dL falls into the moderate hypertriglyceridemia range (200-499 mg/dL), which is associated with increased cardiovascular risk but is below the threshold (≥500 mg/dL) where acute pancreatitis becomes a concern. 1, 2
• The total cholesterol to HDL ratio of 5.4 indicates elevated cardiovascular risk. 1

Primary Treatment: Statin Therapy

Initiate moderate-to-high intensity statin therapy (atorvastatin 20-40 mg or rosuvastatin 10-20 mg daily) as first-line treatment. 1

• Statins provide proven cardiovascular mortality benefit through LDL-C reduction and will simultaneously lower your triglycerides by 10-30% in a dose-dependent manner. 1, 2
• Your LDL-C goal should be <100 mg/dL (or <70 mg/dL if you have additional high-risk features such as diabetes, established cardiovascular disease, or multiple risk factors). 1
• Simvastatin 40 mg daily reduced triglycerides by 28% and LDL-C by 29% in patients with combined hyperlipidemia. 3

Essential Lifestyle Modifications

Target a 5-10% body weight reduction, which produces a 20% decrease in triglycerides—the single most effective lifestyle intervention. 2

• Restrict added sugars to <6% of total daily calories, as sugar intake directly increases hepatic triglyceride production. 1, 2
• Limit total dietary fat to 30-35% of total calories and restrict saturated fats to <7% of total energy intake, replacing with monounsaturated or polyunsaturated fats. 1, 2
• Eliminate or drastically reduce alcohol consumption, as even 1 ounce daily increases triglycerides by 5-10%. 1, 2
• Engage in at least 150 minutes per week of moderate-intensity aerobic activity, which reduces triglycerides by approximately 11%. 1, 2
• Increase soluble fiber to >10 g/day from sources like oats, beans, and vegetables. 1, 2
• Consume at least 2 servings per week of fatty fish (salmon, trout, sardines) rich in omega-3 fatty acids. 1, 2

When to Consider Additional Therapy

If triglycerides remain >200 mg/dL after 3 months of optimized lifestyle modifications and statin therapy, consider adding prescription omega-3 fatty acids (icosapent ethyl 2-4g daily). 1, 2

• Icosapent ethyl is specifically indicated for patients with triglycerides ≥150 mg/dL on maximally tolerated statin therapy who have established cardiovascular disease OR diabetes with ≥2 additional cardiovascular risk factors. 2
• The REDUCE-IT trial demonstrated a 25% reduction in major adverse cardiovascular events with icosapent ethyl (number needed to treat = 21). 2
• Monitor for increased risk of atrial fibrillation with prescription omega-3 fatty acids at doses of 2-4g daily. 2

Monitoring and Follow-Up

Reassess your fasting lipid panel in 6-12 weeks after implementing lifestyle modifications and starting statin therapy. 2

• Your primary goal is to reduce LDL-C to <100 mg/dL and triglycerides to <200 mg/dL (ideally <150 mg/dL). 1, 2
• Your secondary goal is to achieve non-HDL-C <130 mg/dL. 1, 2
• If you develop muscle symptoms while on statin therapy, report them immediately and have creatine kinase levels checked. 2

Critical Pitfalls to Avoid

Do not delay statin therapy while attempting lifestyle modifications alone—if you have elevated cardiovascular risk (10-year ASCVD risk ≥7.5%, diabetes, or established cardiovascular disease), statins should be initiated immediately alongside lifestyle changes. 2

Do not use over-the-counter fish oil supplements expecting cardiovascular benefit—only prescription omega-3 fatty acids (icosapent ethyl) have proven cardiovascular outcomes data. 2

Do not start with fibrate therapy at your triglyceride level—fibrates are reserved for severe hypertriglyceridemia (≥500 mg/dL) to prevent pancreatitis, or as add-on therapy after statin optimization. 1, 2

Risk Assessment Considerations

Before starting treatment, your healthcare provider should:

• Calculate your 10-year ASCVD (atherosclerotic cardiovascular disease) risk using the Framingham risk score or pooled cohort equations to determine statin intensity. 1, 2
• Screen for secondary causes of dyslipidemia: uncontrolled diabetes (check hemoglobin A1c), hypothyroidism (check TSH), chronic kidney disease (check creatinine/eGFR), and medications that raise lipids (thiazide diuretics, beta-blockers, estrogen therapy, corticosteroids). 2
• Assess for metabolic syndrome features: central obesity, hypertension, glucose intolerance, which overlap with your lipid abnormalities and increase cardiovascular risk. 1