What are the recommendations for cholesterol screening, follow‑up intervals, and treatment thresholds in adults?

Cholesterol Screening in Adults

Who to Screen and When to Start

All adults aged 40-75 years should undergo lipid screening with measurement of total cholesterol and HDL cholesterol, regardless of risk factors. 1, 2

Age-Based Screening Initiation:

• Adults 40-75 years: Universal screening is strongly recommended for all individuals in this age range 1, 2

• Adults 20-39 years: Screen only if cardiovascular risk factors are present 1, 2

  • Risk factors warranting early screening include:
    • Diabetes mellitus 2
    • Family history of premature cardiovascular disease (before age 50 in male relatives or age 60 in female relatives) 1, 2
    • Current tobacco use 1, 2
    • Hypertension (BP ≥140/90 mmHg or on antihypertensive medication) 1, 2
    • Obesity 2
    • Multiple coronary heart disease risk factors 1, 2

• Adults >75 years: Routine screening can be discontinued unless the patient is on statin therapy or has specific cardiovascular risk factors requiring continued monitoring 3

What to Measure

The screening lipid panel should include total cholesterol and HDL cholesterol, which can be obtained from either fasting or non-fasting samples. 1, 2

Standard Lipid Profile Components:

• Total cholesterol and HDL cholesterol are the recommended initial screening tests 1, 2
• Either fasting or non-fasting samples are acceptable for initial screening 2
• Confirm abnormal results with a repeat sample on a separate occasion; use the average of both measurements for risk assessment 1, 2

When to Obtain Fasting Samples:

• If non-fasting triglycerides are ≥400 mg/dL (≥4.5 mmol/L), obtain a repeat fasting lipid profile to assess fasting triglyceride levels and calculate LDL cholesterol 1, 2
• For patients with elevated screening results, a complete fasting lipoprotein analysis (total cholesterol, HDL, triglycerides, and calculated or measured LDL cholesterol) provides useful information for treatment selection 1, 2

Screening Intervals

For adults without risk factors and with normal lipid levels, repeat screening every 5 years is appropriate. 1, 2

Interval Modifications Based on Risk:

• Every 5 years: Standard interval for low-risk adults with normal lipid levels 1, 2

• Every 1-2 years: More frequent testing is warranted when: 2

  • Two or more cardiac risk factors are present
  • LDL cholesterol is borderline-high (130-159 mg/dL) or high (≥160 mg/dL)
  • Lipid levels are close to treatment thresholds 1, 2
  • Patient is on lipid-lowering therapy 2
  • Diabetes mellitus is present 2

• Longer intervals: May be appropriate for low-risk persons with repeatedly normal lipid levels 1

Treatment Thresholds and Risk Assessment

Treatment decisions must be based on overall cardiovascular risk assessment, not lipid levels alone. 1

Risk Assessment Framework:

• Integrate lipid results into a global cardiovascular risk score that combines multiple risk factors (age, sex, diabetes, blood pressure, smoking status, family history) 1, 2
• Tools that incorporate specific information on multiple risk factors provide more accurate cardiovascular risk estimation than simply counting risk factors 1

Treatment Considerations:

• Dietary therapy is the primary initial treatment for most patients, though only a minority achieve substantial lipid reductions from diet alone 1
• Drug therapy is frequently needed to achieve therapeutic goals, especially in high-risk patients, and is more effective than diet alone 1
• Treatment choices should account for overall cardiovascular risk, costs, and patient preferences 1

Secondary Prevention (Patients with Established ASCVD):

• In very high-risk patients on maximally tolerated statin therapy with LDL cholesterol ≥70 mg/dL (≥1.8 mmol/L) or non-HDL cholesterol ≥100 mg/dL (≥2.6 mmol/L), adding ezetimibe is reasonable 1
• PCSK9 inhibitors may be considered in very high-risk patients meeting the above criteria after discussion about net benefit, safety, and cost 1

Special Populations

Older Adults (>75 years):

• Routine lipid screening can be discontinued in adults over 75 years without cardiovascular disease or statin therapy 3
• Continue monitoring in those already on statin therapy to assess adherence and efficacy 3
• The predictive value of cholesterol levels for cardiovascular risk diminishes significantly after age 75 3

Young Adults Without Risk Factors:

• Men aged 20-35 years and women aged 20-45 years without risk factors do not require routine screening 1, 2, 3
• The absolute risk reduction from treating dyslipidemia in low-risk young persons is small before middle age 1

Common Pitfalls to Avoid

• Do not rely on a single lipid measurement for diagnosis or treatment decisions; always confirm with a repeat sample 1, 2
• Do not screen all young adults regardless of risk factors, as this leads to unnecessary testing in low-risk individuals 1, 2
• Do not base treatment decisions on lipid levels alone; always incorporate overall cardiovascular risk assessment 1, 2
• Do not routinely order advanced lipoprotein testing (beyond standard lipid profile) for cardiovascular risk assessment in asymptomatic adults 2

Universal Lifestyle Counseling

All patients, regardless of lipid levels, should receive counseling about: 1

• Diet low in saturated fat and high in fruits and vegetables
• Regular physical activity
• Tobacco avoidance
• Maintaining a healthy weight

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