How should I manage a 57-year-old woman with total cholesterol 200 mg/dL, low-density lipoprotein cholesterol 118 mg/dL, and triglycerides 180 mg/dL?

Management of a 57-Year-Old Woman with Total Cholesterol 200 mg/dL, LDL-C 118 mg/dL, and Triglycerides 180 mg/dL

Calculate her 10-year ASCVD risk using the Pooled Cohort Equations before making any treatment decisions, as this single calculation determines whether she needs immediate statin therapy or lifestyle modification alone. 1, 2

Risk Stratification Framework

Your management hinges entirely on her calculated 10-year ASCVD risk, which requires you to assess:

• Blood pressure (current value and whether she's on treatment) 2
• Smoking status 2
• Diabetes status 2
• Race 2
• Family history of premature ASCVD 1, 2

High-Risk Category (≥20% 10-year ASCVD risk OR diabetes OR established CVD)

• Start moderate-to-high intensity statin immediately (atorvastatin 10-20 mg or rosuvastatin 5-10 mg daily) without waiting for lifestyle modification trial 1, 3
• Target LDL-C <100 mg/dL, with optional intensive goal <70 mg/dL if diabetes coexists 1
• Initiate lifestyle modifications simultaneously, not sequentially 3

Intermediate-Risk Category (7.5-20% 10-year ASCVD risk)

• Start moderate-intensity statin therapy (atorvastatin 10-20 mg or rosuvastatin 5-10 mg daily), especially if risk-enhancing factors are present 1, 2
• Target 30-50% LDL-C reduction from baseline 2
• Goal LDL-C <100 mg/dL 3, 2

Borderline-Risk Category (5-7.5% 10-year ASCVD risk)

• Consider statin therapy only if risk-enhancing factors are present (family history of premature ASCVD, history of preeclampsia or premature menopause, chronic inflammatory disorders) 1
• Otherwise, intensive lifestyle modification for 3-6 months 3
• Recheck lipid panel after 12 weeks; initiate statin if LDL-C remains ≥130 mg/dL 3

Low-Risk Category (<5% 10-year ASCVD risk)

• Do not initiate statin therapy 1
• Focus exclusively on intensive lifestyle modifications 1
• Recheck lipid panel after 3-6 months 3

Additional Risk Assessment Tools

Consider coronary artery calcium (CAC) scoring if her risk category is uncertain:

• CAC score = 0: withhold statin therapy 1
• CAC score ≥100 or ≥75th percentile: statin therapy is warranted 1

Mandatory Lifestyle Modifications (Regardless of Risk Category)

Dietary Changes

• Saturated fat <7% of total calories 1, 3, 2
• Dietary cholesterol <200 mg/day 1, 3, 2
• Eliminate all trans-fatty acids 1, 3, 2
• Increase soluble fiber to 10-25 g/day 2
• Emphasize fruits, vegetables, whole grains, low-fat dairy, fish, legumes, and lean protein 1

Physical Activity

• At least 30-60 minutes of moderate-intensity aerobic activity on most days of the week 1, 3, 2
• Add resistance training 2 days per week (8-10 exercises, 1-2 sets, 10-15 repetitions) 2

Weight Management

• Target BMI 18.5-24.9 kg/m² 1, 3, 2
• Target waist circumference <35 inches for women 1, 3, 2

Monitoring Protocol

If Statin Initiated

• Recheck fasting lipid panel 4-12 weeks after statin initiation to assess treatment efficacy 1, 3, 2
• Monitor for statin adverse effects (hepatic aminotransferases, musculoskeletal symptoms) 1
• Once at goal and stable, perform annual lipid monitoring 1, 3

If Lifestyle Modification Alone

• Recheck fasting lipid panel after 12 weeks 2
• If LDL-C remains ≥130 mg/dL after lifestyle intervention, initiate statin therapy 3

Screen for Secondary Causes Before Starting Pharmacotherapy

Obtain these laboratory tests to exclude secondary contributors to dyslipidemia:

• Thyroid-stimulating hormone (TSH) to rule out hypothyroidism 2
• Liver function tests 2
• Fasting glucose or HbA1c to exclude diabetes 2
• Urinalysis to screen for nephrotic syndrome 2

Additional Cardiovascular Risk Factor Management

• Blood pressure control: Target <140/90 mm Hg (or <130/80 mm Hg if diabetes or chronic kidney disease develops) 1, 2
• Diabetes screening: Screen with fasting glucose or HbA1c if obesity and sedentary lifestyle are present; target HbA1c <7% if diabetes is diagnosed 1, 2

Critical Clinical Pitfalls to Avoid

• Do not delay statin initiation in patients with 10-year ASCVD risk ≥7.5% and LDL-C ≥130 mg/dL 1
• Do not rely solely on lifestyle modification when calculated risk is intermediate or high 1
• Do not start statin therapy based solely on lipid values without first calculating ASCVD risk 1
• Age alone should not preclude statin therapy in this 57-year-old woman; trials demonstrate significant absolute risk reduction in women aged 65-82 years with acceptable safety profiles 1

Optimal Lipid Targets for Women

• LDL-C <100 mg/dL 3
• HDL-C >50 mg/dL (higher threshold than men) 3
• Triglycerides <150 mg/dL 3
• Non-HDL-C <130 mg/dL 3