LDL Cholesterol Goals — Extended Reference

For adults without established atherosclerotic cardiovascular disease, an LDL cholesterol goal below 100 mg/dL is commonly appropriate.

For adults at borderline (5 to less than 7.5 percent) or intermediate (7.5 to less than 20 percent) 10-year ASCVD risk, risk-enhancing factors — including family history of premature ASCVD, persistently elevated LDL cholesterol at or above 160 mg/dL, chronic kidney disease, metabolic syndrome, chronic inflammatory conditions, premature menopause, high-risk ancestry, elevated lipoprotein(a), and elevated apolipoprotein B — may support intensification of therapy toward more aggressive LDL cholesterol reduction.

Coronary artery calcium (CAC) scoring may be considered when the decision to initiate statin therapy remains uncertain after clinical risk estimation.

For adults with clinical ASCVD — including prior myocardial infarction, ischemic stroke, symptomatic peripheral artery disease, or a history of coronary revascularization such as CABG or percutaneous coronary intervention — an LDL cholesterol goal below 70 mg/dL is commonly targeted.

For very high-risk ASCVD — defined by a major event plus multiple high-risk conditions — contemporary guidance supports consideration of an LDL cholesterol threshold at or below 55 mg/dL, with addition of ezetimibe and, where appropriate, PCSK9 inhibitor therapy.

For adults with diabetes mellitus aged 40 to 75 without clinical ASCVD, moderate-intensity statin therapy is generally indicated, with escalation to high-intensity statin therapy for those with multiple ASCVD risk factors.

For diabetic patients with established ASCVD, an LDL cholesterol goal below 70 mg/dL, and consideration of an LDL cholesterol threshold at or below 55 mg/dL in very-high-risk circumstances, may be appropriate.

For adults with confirmed heterozygous FH without ASCVD, an LDL cholesterol goal below 70 mg/dL may be reasonable.

For adults with FH and established ASCVD, consideration of an LDL cholesterol threshold at or below 55 mg/dL, with combination therapy as needed, may be appropriate.

For adults 20 to 75 with LDL cholesterol at or above 190 mg/dL, high-intensity statin therapy is generally indicated regardless of calculated risk.

If LDL cholesterol remains at or above 100 mg/dL on maximally tolerated statin therapy, ezetimibe may be added; if still at or above 100 mg/dL, PCSK9 inhibitor therapy may be considered.

Elevated lipoprotein(a), coronary artery calcification, apolipoprotein B elevation, and additional risk-enhancing factors may all justify more intensive LDL cholesterol reduction than a routine calculated risk estimate would otherwise suggest.

Shared decision-making with the patient, review of individual preferences and risk tolerance, and periodic reassessment of the treatment plan remain foundational to appropriate lipid management.