A patient has total cholesterol 233 mg/dL, high‑density lipoprotein cholesterol (HDL‑C) 68 mg/dL, triglycerides 108 mg/dL, low‑density lipoprotein cholesterol (LDL‑C) 143 mg/dL (non‑HDL‑C ≈165 mg/dL). Should treatment be initiated?

Should Treatment Be Initiated for This Lipid Profile?

Yes, statin therapy should be initiated immediately. This patient's lipid profile shows an LDL-C of 143 mg/dL and non-HDL-C of 165 mg/dL, both of which exceed treatment thresholds for most cardiovascular risk categories, and treatment decisions depend critically on the patient's absolute cardiovascular risk assessment 1.

Risk Stratification Is the First Step

Calculate the patient's 10-year ASCVD risk using the Pooled Cohort Equations to determine treatment intensity 2, 1. The decision to treat hinges entirely on this risk assessment:

• If 10-year ASCVD risk ≥7.5%: Initiate moderate-to-high intensity statin therapy immediately 2, 1
• If 10-year ASCVD risk 5-7.5%: Engage in shared decision-making; consider statin initiation given the elevated triglycerides (108 mg/dL) as a risk-enhancing factor 1
• If diabetes mellitus (age 40-75 years): Initiate statin therapy regardless of baseline LDL-C level 1, 3
• If established ASCVD: Initiate high-intensity statin therapy immediately 2, 1

Why This Patient Likely Needs Treatment

The LDL-C of 143 mg/dL exceeds the treatment threshold of 130 mg/dL for most moderate-risk patients (those with 2+ risk factors and 10-year risk 10-20%) 2. Even more importantly, the non-HDL-C of 165 mg/dL substantially exceeds the target of <130 mg/dL for patients with elevated triglycerides 2, 1, 4.

Non-HDL-C is calculated as total cholesterol minus HDL-C (233 - 68 = 165 mg/dL) and represents the total burden of all atherogenic lipoproteins (LDL, VLDL, IDL, and Lp(a)) 4. Non-HDL-C predicts cardiovascular risk as well as or better than LDL-C alone, particularly when triglycerides are elevated 1, 4.

Treatment Algorithm Based on Risk Category

For High-Risk Patients (10-year ASCVD risk ≥20% or diabetes with ASCVD)

Initiate high-intensity statin therapy immediately (atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily) with a target LDL-C <100 mg/dL, and consider an optional target of <70 mg/dL 2, 1. Start lipid-lowering medications before hospital discharge if the patient is hospitalized 2.

For Moderately High-Risk Patients (10-year ASCVD risk 10-20%)

Initiate moderate-to-high intensity statin therapy (atorvastatin 10-20 mg or rosuvastatin 5-10 mg daily) targeting LDL-C <130 mg/dL, with an optional target of <100 mg/dL 2. An LDL-C goal of <100 mg/dL is a reasonable therapeutic option based on clinical trial evidence 2.

For Moderate-Risk Patients (10-year ASCVD risk 7.5-10%)

Initiate moderate-intensity statin therapy targeting LDL-C <130 mg/dL 2, 1. The elevated triglycerides (108 mg/dL) and borderline non-HDL-C favor treatment initiation even at the lower end of this risk range 1.

Specific Statin Recommendations

Start with atorvastatin 10-20 mg daily or rosuvastatin 5-10 mg daily for moderate-intensity therapy, which will achieve a 30-40% LDL-C reduction and bring this patient's LDL-C from 143 mg/dL to approximately 85-100 mg/dL 2, 1, 3. Statins also provide a dose-dependent 10-30% reduction in triglycerides, which will help address the mildly elevated triglyceride level 1, 5.

High-intensity statin therapy (atorvastatin 40-80 mg or rosuvastatin 20-40 mg) achieves ≥50% LDL-C reduction and should be used for very high-risk patients 2, 1, 3.

Concurrent Lifestyle Modifications

Initiate therapeutic lifestyle changes (TLC) simultaneously with statin therapy—do not delay pharmacotherapy while attempting lifestyle changes alone in patients with elevated cardiovascular risk 2, 1:

• Reduce saturated fat to <7% of total calories and replace with monounsaturated or polyunsaturated fats 2, 1
• Limit dietary cholesterol to <200 mg/day 2, 1
• Eliminate trans fats to <1% of total energy 2, 1
• Increase soluble fiber to >10 g/day 2, 1
• Engage in ≥150 minutes/week of moderate-intensity aerobic activity 2, 1
• Target 5-10% weight loss if overweight, which produces a 20% decrease in triglycerides 1, 5

Secondary Treatment Targets

Once LDL-C is at goal, address the non-HDL-C target of <130 mg/dL 2, 1. This patient's non-HDL-C of 165 mg/dL is 35 mg/dL above target. If non-HDL-C remains elevated after achieving LDL-C goal, consider intensifying statin therapy or adding ezetimibe 2, 1.

For triglycerides in the 100-150 mg/dL range, statin therapy alone is typically sufficient 1, 5. Additional triglyceride-lowering therapy (fibrates or omega-3 fatty acids) is generally reserved for triglycerides ≥200 mg/dL after optimized statin therapy 1, 5.

Monitoring Strategy

Reassess fasting lipid panel 4-8 weeks after initiating statin therapy to ensure adequate LDL-C reduction (at least 30-40% from baseline) 2, 1. If LDL-C goal is not achieved, increase the statin dose or add ezetimibe 10 mg daily 1.

Monitor for statin-related adverse effects, particularly muscle symptoms, though the risk of clinical myopathy is low with statin monotherapy 2, 1.

Common Pitfalls to Avoid

Do not delay statin initiation while attempting lifestyle modifications alone in patients with 10-year ASCVD risk ≥7.5% or diabetes—pharmacotherapy and lifestyle optimization should occur simultaneously 2, 1.

Do not use the mildly elevated triglycerides (108 mg/dL) as a reason to defer statin therapy; this level does not require fibrate therapy and will improve with statin treatment 1, 5.

Do not overlook the non-HDL-C of 165 mg/dL, which exceeds the target of <130 mg/dL and indicates significant atherogenic lipoprotein burden requiring treatment 2, 1, 4.

Do not use direct LDL-C measurement instead of calculated LDL-C for treatment decisions, as the evidence base for cholesterol management is derived from trials using calculated LDL-C 6, 7, 8.