I am an adult with a low‑density lipoprotein cholesterol (LDL‑C) level of 135 mg/dL; how should I manage it?

Management of LDL-C 135 mg/dL

Your management depends entirely on your cardiovascular risk category: if you are high-risk (established cardiovascular disease, diabetes, or 10-year risk >20%), you need immediate statin therapy plus lifestyle changes; if you are moderately high-risk (10-year risk 10-20%), you should start therapeutic lifestyle changes now and strongly consider adding a statin; if you are lower-risk, focus on intensive lifestyle modification first. 1

Step 1: Determine Your Risk Category

You must first calculate your 10-year cardiovascular disease risk and identify any high-risk conditions:

• High-risk patients include those with established coronary heart disease, diabetes, peripheral arterial disease, carotid disease, abdominal aortic aneurysm, or calculated 10-year risk >20% 1
• Moderately high-risk patients have 2+ risk factors with 10-year risk of 10-20% 1
• Lower-risk patients have 0-1 risk factors or 10-year risk <10% 1

Step 2: Treatment Based on Risk Category

If You Are High-Risk (Goal: LDL-C <100 mg/dL, Optional <70 mg/dL)

Start both statin therapy and therapeutic lifestyle changes immediately—do not delay. 1, 2

• At your LDL-C of 135 mg/dL, simultaneous initiation of an LDL-lowering drug and dietary therapy is mandatory 1
• Begin a moderate-to-high intensity statin (atorvastatin 40-80 mg daily or rosuvastatin 20-40 mg daily) to achieve at least 30-40% LDL-C reduction 1, 2, 3
• If you have multiple very high-risk features (recent acute coronary syndrome, recurrent events, multiple vascular beds affected), consider targeting LDL-C <70 mg/dL as a therapeutic option 1, 2
• Therapeutic lifestyle changes are non-negotiable even when starting medication: reduce saturated fat to <7% of calories, limit cholesterol to <200 mg/day, eliminate trans fats, add 2g/day plant stanols/sterols, increase soluble fiber to 10-25g/day, and engage in 30+ minutes of moderate exercise most days 3, 4

If You Are Moderately High-Risk (Goal: LDL-C <130 mg/dL, Optional <100 mg/dL)

Begin therapeutic lifestyle changes immediately; drug therapy is strongly recommended at your current level. 1

• Your LDL-C of 135 mg/dL exceeds the treatment threshold of ≥130 mg/dL for moderately high-risk patients 1, 2
• Initiate the same intensive lifestyle modifications described above 1, 4
• After implementing lifestyle changes, if LDL-C remains ≥130 mg/dL, start a moderate-intensity statin (atorvastatin 10-20 mg or rosuvastatin 5-10 mg daily) to achieve the <130 mg/dL goal 1, 2, 4
• Achieving an LDL-C <100 mg/dL represents a reasonable therapeutic option based on primary prevention trial evidence showing additional cardiovascular benefit 1
• The American College of Cardiology recommends not delaying statin initiation for an extended trial of lifestyle changes alone when LDL is ≥130 mg/dL in moderately high-risk patients 4

If You Are Lower-Risk (Goal: LDL-C <160 mg/dL)

Focus on intensive therapeutic lifestyle changes as your primary intervention. 1, 3

• At 135 mg/dL, you are below the drug therapy threshold of 160 mg/dL for lower-risk individuals 3
• Implement the comprehensive lifestyle modifications: saturated fat <7% of calories, cholesterol <200 mg/day, no trans fats, plant stanols/sterols 2g/day, soluble fiber 10-25g/day, regular physical activity 3, 4
• Reassess lipid levels after 6-12 weeks of lifestyle intervention 4
• Drug therapy becomes appropriate only if LDL-C remains ≥160 mg/dL after adequate lifestyle trial, or if LDL-C is ≥190 mg/dL at any time 3

Step 3: Monitoring and Follow-Up

• Obtain baseline liver function tests before starting any statin therapy 5
• Reassess lipid profile 4-6 weeks after initiating or changing therapy 3, 4
• Monitor for muscle pain, tenderness, or weakness, especially if accompanied by malaise or fever—these are potential signs of statin-related myopathy 5
• Continue monitoring every 3-6 months initially, then annually once stable on therapy 3

Step 4: Escalation if Goals Not Met

If you fail to reach your LDL-C goal on maximally tolerated statin therapy:

• Add ezetimibe 10 mg daily, which provides an additional 15-25% LDL-C reduction 3, 6
• For refractory cases despite statin plus ezetimibe, PCSK9 inhibitors (evolocumab or alirocumab) can provide an additional 50-70% LDL-C reduction 3, 6, 7

Critical Pitfalls to Avoid

• Do not wait to start medication in high-risk patients—at LDL-C ≥130 mg/dL, immediate combined drug and lifestyle therapy is indicated 1, 2
• Do not underestimate the importance of lifestyle changes—they must be implemented regardless of whether drug therapy is started 1, 2
• Do not use antacids containing aluminum and magnesium hydroxide within 2 hours of taking rosuvastatin, as they interfere with absorption 5
• Do not continue statins if you become pregnant—inform your healthcare provider immediately to discuss discontinuation 5
• Do not assume lower-risk status without formal risk calculation—many patients underestimate their cardiovascular risk 2, 4