LDL Cholesterol Goal Ranges
For patients with high cholesterol or cardiovascular disease, the LDL-C goal is <100 mg/dL as a minimum target, with <70 mg/dL representing a reasonable and preferred therapeutic option for very high-risk patients, and <55 mg/dL for those with established atherosclerotic cardiovascular disease or recurrent events. 1
Risk-Stratified LDL Goals
Very High-Risk Patients: Goal <70 mg/dL (or <55 mg/dL)
Very high-risk patients should target LDL-C <70 mg/dL, or achieve at least a 50% reduction from baseline if starting between 70-135 mg/dL. 1
Very high-risk status is defined by:
- Established atherosclerotic cardiovascular disease (prior MI, stroke, peripheral arterial disease) 1
- Recurrent cardiovascular events despite optimal therapy warrant an even more aggressive goal of <40 mg/dL 1
- Diabetes with target organ damage 2
- Severe chronic kidney disease 3
- Multiple major risk factors, especially poorly controlled 2
The evidence supporting <70 mg/dL comes from landmark trials showing continued benefit below 100 mg/dL, with no identified threshold below which further lowering becomes harmful. 4 The HPS and PROVE IT trials demonstrated that patients with baseline LDL-C <100 mg/dL still achieved significant risk reduction with further lowering, with PROVE IT showing a median LDL-C of 62 mg/dL producing 16% additional reduction in major cardiovascular events compared to achieving 95 mg/dL. 4
High-Risk Patients: Goal <100 mg/dL
High-risk patients should achieve LDL-C <100 mg/dL as the primary target. 4, 1
High-risk status includes:
- Multiple cardiovascular risk factors without established disease 1
- Diabetes without target organ damage 2
- Target organ damage from hypertension 3
- Moderate chronic kidney disease 1
- 10-year Framingham risk ≥20% 4
This goal represents the minimal acceptable target, not the level of maximal benefit. 4 The log-linear relationship between LDL-C and CHD risk continues below 100 mg/dL, suggesting additional benefit from more aggressive lowering. 4
Moderately High-Risk Patients: Goal <130 mg/dL (with <100 mg/dL as therapeutic option)
For moderately high-risk patients (≥2 risk factors and 10-year risk 10-20%), the recommended LDL-C goal is <130 mg/dL, though <100 mg/dL represents a reasonable therapeutic option based on recent trial evidence. 4, 1
Treatment Intensity Requirements
When LDL-lowering drug therapy is employed in high-risk or moderately high-risk patients, intensity should be sufficient to achieve at least a 30-40% reduction in LDL-C levels. 4, 3, 2
Therapeutic Approach:
- Very high-risk patients should initiate high-intensity statin therapy immediately, regardless of baseline LDL-C 1
- If baseline LDL-C ≥130 mg/dL, simultaneous initiation of statin and therapeutic lifestyle changes is recommended 1
- For very high-risk patients not at goal, add ezetimibe (can reduce LDL-C by up to 47%) 1
- If still not at goal after statin plus ezetimibe, add PCSK9 inhibitors or bempedoic acid 1
Critical Implementation Points
All patients with lifestyle-related risk factors (obesity, physical inactivity, elevated triglycerides, low HDL-C, metabolic syndrome) require therapeutic lifestyle changes regardless of LDL-C level. 4, 1
Common Pitfalls to Avoid:
- The 100 mg/dL goal should not be viewed as a ceiling—it is explicitly a minimal goal, not maximal benefit 4
- Standard-dose statins achieve <100 mg/dL in only about half of high-risk patients, requiring dose escalation or combination therapy in the remainder 4
- Real-world data shows only 35% of coronary artery disease patients achieve the <70 mg/dL goal despite 79% achieving <100 mg/dL, indicating significant undertreatment 5
The evidence consistently demonstrates that "lower is better" for LDL-C in reducing cardiovascular morbidity and mortality, with no safety threshold identified above which further lowering becomes harmful. 1, 2