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Trying to lower stubbornly high LDL cholesterol?

November 1, 2022
By Dara K. Lee Lewis, MD, Contributor
Expert consensus focuses on individual planning to bring down elevated LDL.

An orange plastic rack holding blood test tubes with different color tops; yellow top on tube in foreground labeled "LDL Test"

Recently I met with Nancy, a 72-year-old woman with coronary artery disease, to review her latest cholesterol results. Despite taking a statin, following a healthy diet, and exercising regularly, her low-density lipoprotein (LDL) cholesterol remained above our target. "What else can I do?" she asked. "When I increase my statin dose I get terrible leg pains. But I don’t want to have another heart attack!"

When elevated, LDL contributes to cardiovascular disease, which can cause a heart attack or stroke. Taking statin drugs can drop LDL levels in most people by about 30%, substantially lowering this risk. Usually, these commonly prescribed drugs work effectively with tolerable side effects. But what if a person’s LDL level remains too high on their maximally tolerated dose? An expert consensus report issued by the American College of Cardiology lays out a clear path for next steps.

What is a healthy target for LDL cholesterol?

Target LDL depends on many factors, including your age, family history, and personal history of cardiovascular disease. For people at intermediate risk, LDL should be lowered by 30% to 50%. For those who have already had a heart attack, target LDL is no more than 70 mg/dl (note: automatic download).

Which non-statin therapies are recommended first?

Five non-statin therapies described in this post aim to help people achieve target LDL goals while minimizing side effects. They may be combined with a statin or given instead of statins.

Each helps lower LDL cholesterol when diet and statins are not sufficient, such as when there is a family history of high cholesterol (familial hypercholesterolemia). But so far, only two options are proven to reduce cardiovascular risk — the risk for heart attack, stroke, heart failure, and other issues affecting the heart and blood vessels.