Given a total cholesterol of 204 mg/dL, HDL‑cholesterol of 76 mg/dL, triglycerides of 69 mg/dL, LDL‑cholesterol of 112 mg/dL, and non‑HDL cholesterol of 128 mg/dL, what is the appropriate management?

Lipid Management for Borderline-High Total Cholesterol with Favorable HDL

Your lipid profile shows borderline-high total cholesterol (204 mg/dL) but with excellent HDL (76 mg/dL), low triglycerides (69 mg/dL), and borderline LDL (112 mg/dL)—the primary decision hinges on your absolute cardiovascular risk, which determines whether you need statin therapy or lifestyle modification alone. 1

Risk Stratification is Essential

• Calculate your 10-year ASCVD risk using the Pooled Cohort Equations before making any treatment decision, as this determines the intensity of intervention needed 1
• If your 10-year ASCVD risk is ≥7.5%, initiate moderate-to-high intensity statin therapy immediately 1
• If your risk is <7.5%, therapeutic lifestyle changes alone may be sufficient 1

Interpreting Your Specific Numbers

Total Cholesterol: 204 mg/dL

• This falls in the borderline-high category (200-239 mg/dL range) 2
• However, total cholesterol alone is insufficient for treatment decisions—your lipoprotein profile matters more 2

LDL-C: 112 mg/dL

• This is in the borderline range (110-129 mg/dL) by pediatric/young adult standards 2
• For adults with moderate cardiovascular risk, the target is <130 mg/dL; for high-risk patients, <100 mg/dL 2, 1
• Your LDL is just above the optimal threshold of 110 mg/dL but below the treatment threshold for most moderate-risk patients 2, 1

Non-HDL-C: 128 mg/dL

• This is below the target of <130 mg/dL for high-risk patients with elevated triglycerides 2
• Non-HDL-C captures all atherogenic lipoproteins and is a powerful predictor of cardiovascular events 3, 4, 5
• Your non-HDL-C is favorable and does not require intensification of therapy 3

HDL-C: 76 mg/dL

• This is well above the protective threshold of 40 mg/dL and represents a significant protective factor 2
• High HDL reduces your cardiovascular risk independent of LDL levels 2

Triglycerides: 69 mg/dL

• This is optimal (well below 150 mg/dL) and requires no specific intervention 2

Treatment Algorithm Based on Risk Category

If 10-Year ASCVD Risk is <7.5% (Lower Risk)

• Initiate therapeutic lifestyle changes as primary intervention 1
  • Reduce saturated fat to <7% of total calories 2, 1
  • Limit dietary cholesterol to <200 mg/day 2, 1
  • Eliminate trans fats to <1% of energy intake 2, 1
  • Add soluble fiber >10 g/day 2, 1
  • Engage in ≥150 minutes/week of moderate-intensity aerobic activity 1
  • Achieve 5-10% weight loss if overweight 1
• Recheck fasting lipid panel in 3-6 months to assess response 2
• No statin therapy needed at this time if lifestyle modifications are effective 1

If 10-Year ASCVD Risk is 7.5-10% (Moderate Risk)

• Initiate moderate-intensity statin therapy (atorvastatin 10-20 mg or rosuvastatin 5-10 mg daily) with an LDL-C target <130 mg/dL 1
• Implement lifestyle changes concurrently—do not delay pharmacotherapy 1
• This regimen typically lowers LDL-C by 30-40%, which would reduce your 112 mg/dL to approximately 67-78 mg/dL 1

If 10-Year ASCVD Risk is ≥10% (Moderately High to High Risk)

• Initiate moderate-to-high intensity statin (atorvastatin 10-40 mg or rosuvastatin 5-20 mg daily) targeting LDL-C <100 mg/dL 2, 1
• An optional more aggressive target is <70 mg/dL for very high-risk patients 2, 1
• Start statin therapy immediately alongside lifestyle modifications 1

If Established ASCVD (Prior MI, Stroke, or Revascularization)

• Initiate high-intensity statin (atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily) immediately 1, 6
• Target LDL-C <70 mg/dL with ≥50% reduction from baseline 6
• If LDL-C remains elevated on maximally tolerated statin, add ezetimibe 10 mg daily 6

Monitoring and Follow-Up

• Remeasure fasting lipid panel 4-8 weeks after initiating statin therapy to confirm at least a 30-40% LDL-C reduction 1
• Monitor for statin-related adverse effects, though clinical myopathy incidence is low with monotherapy 1
• Once LDL-C is at target, reassess non-HDL-C; if it exceeds <130 mg/dL, consider intensifying statin dose or adding ezetimibe 1, 3

Critical Clinical Considerations

• Your favorable HDL (76 mg/dL) and low triglycerides (69 mg/dL) significantly mitigate cardiovascular risk despite borderline total cholesterol 2
• The total cholesterol/HDL ratio (204/76 = 2.68) is excellent—ratios <3.5 are associated with lower cardiovascular risk 7
• Do not rely on total cholesterol alone for treatment decisions; your lipoprotein subfractions are more informative 2, 8
• If you are a child or adolescent (age 2-19), these values are interpreted differently: total cholesterol >200 mg/dL is considered high, and LDL >110 mg/dL warrants dietary intervention 2

Common Pitfalls to Avoid

• Do not initiate statin therapy based solely on total cholesterol without calculating ASCVD risk 1
• Do not delay lifestyle modifications while waiting to see if pharmacotherapy is needed—start dietary and activity changes immediately 1
• Do not ignore the protective effect of high HDL—your HDL of 76 mg/dL substantially lowers cardiovascular risk 2
• Do not use over-the-counter niacin as a substitute for prescription therapy if lipid-modifying drugs become necessary 3