Target levels for cholesterol: Cholesterol: Types, Tests, Treatments, Prevention
Cholesterol: Types, Tests, Treatments, Prevention
Cholesterol in the blood and blood vessel.
What is cholesterol?
You probably have heard about cholesterol, but you might not be sure exactly what it is. Cholesterol is a waxy type of fat, or lipid, which moves throughout your body in your blood. Lipids are substances that do not dissolve in water, so they do not come apart in blood. Your body makes cholesterol, but you can also get it from foods. Cholesterol is only found in foods that come from animals.
Why is cholesterol important to our bodies?
Every cell in the body needs cholesterol, which helps the cell membranes form the layers. These layers protect the contents of the cell by acting as the gatekeeper to what things can enter or leave the cell. It is made by the liver and is also used by the liver to make bile, which helps you digest foods. Cholesterol is also needed to make certain hormones and to produce vitamin D. Your liver makes enough cholesterol to meet your body’s needs for these important functions.
What are the types of cholesterol?
Cholesterol moves throughout the body carried by lipoproteins in the blood. These lipoproteins include:
- Low-density lipoprotein (LDL) is one of the two main lipoproteins. LDL is often called “the bad cholesterol.”
- High-density lipoprotein (HDL) is the other main lipoprotein. HDL is often called “the good cholesterol.”
- Very-low-density lipoproteins (VLDL) are particles in the blood that carry triglycerides.
If cholesterol is necessary, why do we have to worry about how much we have?
Having enough cholesterol to meet your needs is important. Having too much cholesterol can cause problems. If your cholesterol levels are high, the condition is called hypercholesterolemia. If your cholesterol levels are low, the condition is called hypocholesterolemia. It is not common to have cholesterol levels that are too low, but it can happen.
What is low-density lipoprotein (LDL)?
You might think it is weird that the low-density lipoprotein is called the bad cholesterol when we always hear about how we should lower our cholesterol. However, LDL is “bad” because of what it does.
LDL can build up on the walls of your arteries and make them narrower.The fatty deposits form plaque that lines your arteries and may cause blockages. This build-up is called atherosclerosis.
Arteries are the blood vessels that carry oxygen-rich blood away from your heart to all other organs in the body.
The fats linked to LDL cholesterol levels and those that you should minimize in your diet are called saturated fats and trans fats. Saturated fats are solid or wax-like when they are at room temperature. You mostly find saturated fats in products that come from animals, such as meat, milk, cheese and butter.
Trans fats result when liquid fats are put through the hydrogenation process to become solid. Trans fats are found in fast foods and fried foods and are used to extend the shelf-life of processed foods like cookies, crackers and bakery.
What is high-density lipoprotein (HDL)?
HDL is called the “good cholesterol.” It is good because it carries away other kinds of cholesterol. (including LDL), away from the arteries. It might help to think of HDL as a delivery truck, while thinking of LDL as a dump truck. HDL drops other types of cholesterol off at the liver and they are removed from the body. It is believed that higher levels of HDL reduce the risk for heart disease.
What kind of test measures cholesterol?
Everyone over the age of 20 should get their cholesterol levels measured at least once every five years.Your healthcare provider will order a blood test that will indicate how much cholesterol is carried in your bloodstream. This test will give your cholesterol levels. Your provider might also order what is called a lipid panel or a lipid profile. The panel gives you the following numbers:
- Total cholesterol.
- LDL levels.
- HDL levels.
- VLDL levels and triglycerides.
- Non-HDL cholesterol.
- Ratio between cholesterol and HDL.
There are advanced tests that break down the size and shapes of LDL cholesterol levels, and also give the LDL particle number, but those are not normally ordered. Some test makers say that the more advanced tests are better at indicating who is at risk for heart disease, but most providers still feel that the usual tests are adequate.
How is the total cholesterol, or blood cholesterol, test done?
A blood test is a routine test. A phlebotomist is the person whose job it is to draw blood. Blood is usually drawn from the vein in your arm. You will sit down and the phlebotomist will wrap a rubber band around your upper arm so that the vein in your elbow sticks out. Then they will use a needle to puncture the vein and remove blood. The blood is sent to the lab to be examined.
You’ve probably been at health fairs where testing is offered. In that case, the person performing the test takes a drop of blood from your finger. The finger stick test uses a small blade to poke a hole in the tip of your finger to get the blood.
How do you prepare for a cholesterol test?
In most cases, you’ll need to fast for nine to 12 hours before the test. Make sure you tell the person drawing your blood how long it has been since you ate or drank anything that wasn’t water.
There are some cases when a cholesterol test is done without fasting. This is true for tests done at health screenings and may be true for people younger than 20 or for people who are unable to fast.
Some medical societies believe that fasting is not necessary to get a true picture of lipid levels in the blood, while other associations stand by the belief that fasting gives a better idea of a person’s heart disease risk. You should be clear on whether or not you need to fast, and for how long, before you go for the blood test.
How long does it take to get results from a cholesterol test?
Your results will often be available within a day or two. In the case of screenings and finger stick tests, you’ll get results immediately. In either case, you’ll want to speak with your healthcare provider to discuss the results. The results are often given as milligrams per deciliter (mg/dL).
Are home cholesterol testing kits accurate?
The answer is yes if the tests are labeled “CDC-certified.” This means that the contents have been approved by the Cholesterol Reference Method Laboratory Network, a group that works with test makers, laboratories and the Centers for Disease Control and Prevention (CDC) to make sure tests are accurate.
For home tests, you will still need to fast for 12 hours and to obtain blood for testing. Some kits come with packages for mailing to a lab for results. Other kits have a monitor so you can get the results at home. The cost of such home kits vary.
What are normal levels of cholesterol?
Normal levels of cholesterol are different depending on your age and sex. These guidelines show desirable total, non-HDL,LDL and HDL levels by age and sex.
Table 1: Target cholesterol levels by age and sex
|Age and sex||
|People aged 19 years
|Less than 170 mg/dL||Less than 120 mg/dL||Less than 110 mg/dL||More than 45 mg/dL|
|Men aged 20 years
|125 mg/dL to 200 mg/dL||Less than 130 mg/dL||Less than 100 mg/dL||40 mg/dL or higher|
|Women aged 20 years
|125 mg/dL to 200 mg/dL||Less than 130 mg/dL||Less than 100 mg/dL||50 mg/dL or higher|
The table above spells out the numbers for normal cholesterol levels. The table below shows you cholesterol levels that are higher than normal. High cholesterol numbers vary by age group and sex, and may be different for those who have heart disease. These guidelines represent high cholesterol numbers for those who do not have heart disease.
Table 2: High total, non-HDL and LDL cholesterol levels by age and sex
|Age and sex||Total cholesterol||Non-HDL cholesterol||LDL cholesterol|
|People aged 19 years and younger (children and teens)||
Borderline: 170-199 mg/dL
High: Greater than or equal to 200 mg/dL
Borderline: 120-144 mg/dL
High: Greater than or equal to 145 mg/dL
Borderline: 110-129 mg/dL
High: Greater than or equal to 130 mg/dL
|Men aged 20 years
Borderline: 200-239 mg/dL
High: Greater than or equal to 239 mg/dL
|High: Greater than 130 mg/dL||
Near optimal or above optimal: 100-129 mg/dL
Borderline high: 130-159 mg/dL
High: 160-189 mg/dL
Very high: Greater than 189 mg/dL
|Women aged 20 years
Borderline: 200-239 mg/dL
High: Greater than or equal to 239 mg/dL
|High: Greater than 130 mg/dL||
Near optimal or above optimal: 100-129 mg/dL
Borderline high: 130-159 mg/dL
High: 160-189 mg/dL
Very high: Greater than 189 mg/dL
LDL cholesterol levels
If you do not have heart disease or blood vessel disease, and you are not at high risk for developing heart disease, the optimal (or best) number is less than 100 mg/dL.
If you do have heart or blood vessel disease, or a number of risk factors, your healthcare provider may want your LDL level to be lower than 70 mg/dL. If you have diabetes, your healthcare provider will want your LDL level to be below 100 mg/dL or even below 70 mg/dL.
Triglycerides are important because most of the fat in your body exists as triglycerides. These levels are often higher in people who have diabetes or who are obese. For triglycerides, the details that you want to know about the numbers are:
- Normal if they are less than 150.
- Borderline high if they are 150-199.
- High if they are 200-499.
- Very high if they are 500 or higher.
HDL cholesterol levels
The number that you want to be higher is the number for HDL (remember, it’s the good cholesterol).
- HDL under 40 is considered poor and a risk factor for heart disease in men and women.
- HDL goal for men is 40 or higher and reaching this is considered to be good.
- HDL goal for women is 50 or higher and reaching this is considered to be good.
- HDL of 60 or more is considered to be optimum and a protection against heart disease.
Can “bad” cholesterol levels be too low? Can “good” cholesterol levels be too high?
It isn’t often that people have bad cholesterol that is too low or good cholesterol that is too high. There are studies being done that suggest that extremes of any kind are not healthy for everyone.
Even though there is no clear-cut number about what LDL level is too low, levels under 40 mg/dL may be associated with certain health issues, including depression/anxiety, and hemorrhagic stroke.
However, there is data from clinical trials to support that there is no evidence of harm when LDLs remain <40mg/dl on statin therapy.
In some cases, genetic conditions can cause you to have very low cholesterol levels. In other cases, nutritional problems, some cancers, hypothyroidism and certain infections can also cause low cholesterol levels. In any of these types of situations, the underlying issues need to be addressed.
In terms of having too much of a good thing, researchers are studying the effects of too much HDL, the good cholesterol. No conclusions have been reached, but there have been studies into the possible relationship between high HDL and cancer, and a greater risk of heart attack among the high risk. Excessively high HDL may be dysfunctional HDL and not protective.
What factors affect cholesterol levels?
A variety of factors can affect your cholesterol levels. They include:
- Diet: Saturated fat, trans fat and cholesterol in the food you eat increase cholesterol levels. Try to reduce the amount of saturated fat, trans fat and cholesterol in your diet. This will help lower your blood cholesterol level. Saturated and trans fat have the most impact on blood cholesterol.
- Weight: In addition to being a risk factor for heart disease, being overweight can also increase your triglycerides. Losing weight may help lower your triglyceride levels and raise your HDL.
- Exercise: Regular exercise can lower total cholesterol levels. Exercise has the most effect on lowering triglycerides and raising HDL. You should try to be physically active for 30 minutes on most days of the week.
- Age and sex: As we get older,cholesterol levels rise. Before menopause, women tend to have lower total cholesterol levels than men of the same age. After menopause, however, women’s LDL levels tend to rise and HDL can drop.
- Heredity: Your genes partly determine how much cholesterol your body makes. High blood cholesterol can run in families.
What should you know about cholesterol and heart disease?
Preventing and treating heart disease is the main reason that your healthcare provider looks at cholesterol levels. Heart disease is a general term that might apply to many conditions, but in this instance, we are talking about coronary artery disease (CAD).
How is high cholesterol treated?
There are several ways to lower high blood cholesterol (total cholesterol), including lifestyle changes or medication, or both. Your healthcare provider will work with you to determine which therapy (or combination of therapies) is best for you.
Healthcare providers like to start with the least invasive treatments when possible, such as lifestyle changes. You’ll be advised to:
- Avoid tobacco. If you do smoke, quit. Smoking is bad for you in many ways, and reducing your level of good cholesterol is one of them.
- Change the way you eat. Limit the amount of trans fats and saturated fat. Eat heart-healthy foods like fruits, vegetables, poultry, fish and whole grains. Limit red meat, sugary products and dairy products made with whole milk.
- Get more exercise. Try to get about 150 minutes of physical activity every week, or about 30 minutes per day for most days of the week.
- Keep a healthy weight. If you need to lose weight, talk to your healthcare provider about safe ways to do this. You’ll see results even before you reach your ideal weight. Losing even 10% of your body weight makes a difference in your cholesterol levels.
- Reduce the effect of negative emotions. Learn healthy ways to deal with anger, stress or other negative emotions.
- Control blood sugar and blood pressure. Make sure you follow your healthcare provider’s instructions for blood sugar levels, especially if you have diabetes, and for keeping blood pressure in the healthy range.
There are several different types of medications that are designed to treat high cholesterol levels.
Statin medications are one of the most well-known categories of cholesterol drugs. Statins work by reducing the amount of cholesterol produced by the liver. Statins lower blood cholesterol and may help reduce the risk of heart attacks and strokes, which is one reason why they are so widely prescribed. Statins that are available in the U.S. include:
- Atorvastatin (Lipitor®).
- Fluvastatin (Lescol®, Lescol XL®).
- Lovastatin (Mevacor®, Altoprev®).
- Pravastatin (Pravachol®).
- Simvastatin (Zocor®).
- Pitavastatin (Livalo®, Zypitamag®).
Statins are also available in combination medications, such as Advicor® (lovastatin and niacin), Caduet® (atorvastatin and amlodipine) and Vytorin® (simvastatin and ezetimibe).
Statins are not advisable for every person with high cholesterol, especially for those with liver problems. Although side effects are not very common, they can include muscle pain, higher blood glucose levels and memory issues.
Bile acid sequestrants or bile acid-binding drugs are another class of medications that treat high cholesterol levels. The drugs, also called resins, cling to the bile acid, which then cannot be used for digestion. In response, the liver makes more bile by using up more cholesterol. These drugs include:
- Cholestyramine (Questran®, Questran® Light).
- Colestipol (Colestid®).
- ColesevelamHcl (WelChol®).
Resins are not appropriate for everyone. These drugs also have side effects such as constipation and stomach pain.
Fibrates are also called fibric acid derivatives. They are more effective at cutting triglyceride levels than reducing LDL cholesterol. They may also help to boost levels of HDL cholesterol. These products include:
- Fenofibrate (Antara®, Tricor®, Fenoglide®, Fibricor®, Lipidil®, Lipofen®, Trilipix® and Triglide®)
- Gemfibrozil (Lopid®)
Other classes of drugs that healthcare provider might suggest to decrease LDL cholesterol include:
- PCSK9 inhibitors, including alirocumab and evolocumab.
- Selective cholesterol absorption inhibitors, such as ezemtimibe (Zetia®).
- Adenosine triphosphate-citrate lyase (ACL) inhibitors, such as bempedoic acid (Nexletol®).
- Omega 3 fatty acids and fatty acid esters.
- Nicotinic acid, also known as niacin.
You might be given a prescription for these medicines if you are taking a statin and have not been able to reduce LDL to levels that your provider feels are low enough.
For people who are not helped enough by lifestyle changes and medication, often those with a genetic issue, there is a process called lipoprotein apheresis. This means using equipment to remove lipoproteins from blood and plasma and then return the blood and plasma to the body. This process might be combined with some of the new drug treatments.
What complications are possible if you don’t treat high cholesterol levels in your blood?
The main reason to treat high cholesterol is to prevent or treat coronary heart disease (CHD), also called coronary artery disease or CAD. CHD happens when heart is not able to get enough oxygen-rich blood to function well and kills more people in the U.S. than any other cause of death. CHD usually refers to the large arteries, but there is also a condition called coronary microvascular disease that affects the small vessels and causes damage.
Can you get rid of cholesterol deposits?
Researchers are working on ways to eliminate plaque (cholesterol deposits) from coronary arteries. One method that has been proposed involves using combinations of medicines (statins and PCSK9 inhibitors) in healthy people aged 25 to 55 years. It is suggested that getting the levels of cholesterol down very low will allow arteries to clear up and heal up.
Several researchers believe that the way to reverse heart disease, and to prevent it in the first place, is found in a whole food, plant-based diet. Studies have been done that have shown that limiting nutrition to whole foods that are plant-based have been successful in reducing blood cholesterol and even, in some cases, lessening plaque buildup.
How can you prevent high cholesterol levels and coronary heart disease (CHD)?
Prevention methods are very much the same as treatment methods. First, don’t smoke. If you do smoke, make plans to quit now. Find ways to add physical activity to each of your days. Take steps to keep your weight in a healthy range. Eat well. Consider following the Mediterranean diet. It is the only diet proven to reduce the risk of heart disease. Take care of any other medical conditions you might have by following your healthcare provider’s advice and instructions. Learn to really relax and calm down.
When should you contact your healthcare provider about your cholesterol levels?
In truth, your healthcare provider will probably talk to you about your numbers first. As always, contact your provider if you have any new or worsening pain or other uncomfortable feelings. Make sure you know what medications you take and what they are expected to do. Call the provider if you have a reaction to the medicine.
Before you go to the office, and after you have had a cholesterol test, it helps to have a list of questions prepared about your test results and any proposed treatment.
A note from Cleveland Clinic
When considering cholesterol numbers, it’s important to remember that you really have the ability to make those numbers go in your favor. What you choose to eat, how much you are able to move and how you deal with life’s ups and downs are things that you can influence.
What You Need to Know: MedlinePlus
What is cholesterol?
Cholesterol is a waxy, fat-like substance that’s found in all the cells in your body. Your liver makes cholesterol, and it is also in some foods, such as meat and dairy products. Your body needs some cholesterol to work properly. But if you have too much cholesterol in your blood, you have a higher risk of coronary artery disease.
How do you measure cholesterol levels?
A blood test called a lipoprotein panel can measure your cholesterol levels. Before the test, you’ll need to fast (not eat or drink anything but water) for 9 to 12 hours. The test gives information about your
- Total cholesterol – a measure of the total amount of cholesterol in your blood. It includes both low-density lipoprotein (LDL) cholesterol and high-density lipoprotein (HDL) cholesterol.
- LDL (bad) cholesterol – the main source of cholesterol buildup and blockage in the arteries
- HDL (good) cholesterol – HDL helps remove cholesterol from your arteries
- Non-HDL – this number is your total cholesterol minus your HDL. Your non-HDL includes LDL and other types of cholesterol such as VLDL (very-low-density lipoprotein).
- Triglycerides – another form of fat in your blood that can raise your risk for heart disease, especially in women
What do my cholesterol numbers mean?
Cholesterol numbers are measured in milligrams per deciliter (mg/dL). Here are the healthy levels of cholesterol, based on your age and gender:
Anyone age 19 or younger:
|Type of Cholesterol||Healthy Level|
|Total Cholesterol||Less than 170mg/dL|
|Non-HDL||Less than 120mg/dL|
|LDL||Less than 100mg/dL|
|HDL||More than 45mg/dL|
Men age 20 or older:
|Type of Cholesterol||Healthy Level|
|Total Cholesterol||125 to 200mg/dL|
|Non-HDL||Less than 130mg/dL|
|LDL||Less than 100mg/dL|
|HDL||40mg/dL or higher|
Women age 20 or older:
|Type of Cholesterol||Healthy Level|
|Total Cholesterol||125 to 200mg/dL|
|Non-HDL||Less than 130mg/dL|
|LDL||Less than 100mg/dL|
|HDL||50mg/dL or higher|
Triglycerides are not a type of cholesterol, but they are part of a lipoprotein panel (the test that measures cholesterol levels). A normal triglyceride level is below 150 mg/dL. You might need treatment if you have triglyceride levels that are borderline high (150-199 mg/dL) or high (200 mg/dL or more).
How often should I get a cholesterol test?
When and how often you should get a cholesterol test depends on your age, risk factors, and family history. The general recommendations are:
For people who are age 19 or younger:
- The first test should be between ages 9 to 11
- Children should have the test again every 5 years
- Some children may have this test starting at age 2 if there is a family history of high blood cholesterol, heart attack, or stroke
For people who are age 20 or older:
- Younger adults should have the test every 5 years
- Men ages 45 to 65 and women ages 55 to 65 should have it every 1 to 2 years
What affects my cholesterol levels?
A variety of things can affect cholesterol levels. These are some things you can do to lower your cholesterol levels:
- Diet. Saturated fat and cholesterol in the food you eat make your blood cholesterol level rise. Saturated fat is the main problem, but cholesterol in foods also matters. Reducing the amount of saturated fat in your diet helps lower your blood cholesterol level. Foods that have high levels of saturated fats include some meats, dairy products, chocolate, baked goods, and deep-fried and processed foods.
- Weight. Being overweight is a risk factor for heart disease. It also tends to increase your cholesterol. Losing weight can help lower your LDL (bad) cholesterol, total cholesterol, and triglyceride levels. It also raises your HDL (good) cholesterol level.
- Physical Activity. Not being physically active is a risk factor for heart disease. Regular physical activity can help lower LDL (bad) cholesterol and raise HDL (good) cholesterol levels. It also helps you lose weight. You should try to be physically active for 30 minutes on most, if not all, days.
- Smoking. Cigarette smoking lowers your HDL (good) cholesterol. HDL helps to remove bad cholesterol from your arteries. So a lower HDL can contribute to a higher level of bad cholesterol.
Things outside of your control that can also affect cholesterol levels include:
- Age and Sex. As women and men get older, their cholesterol levels rise. Before the age of menopause, women have lower total cholesterol levels than men of the same age. After the age of menopause, women’s LDL (bad) cholesterol levels tend to rise.
- Heredity. Your genes partly determine how much cholesterol your body makes. High blood cholesterol can run in families.
- Race. Certain races may have an increased risk of high blood cholesterol. For example, African Americans typically have higher HDL and LDL cholesterol levels than whites.
How can I lower my cholesterol?
There are two main ways to lower your cholesterol:
- Heart-healthy lifestyle changes, which include:
- Heart-healthy eating. A heart-healthy eating plan limits the amount of saturated and trans fats that you eat. Examples include the Therapeutic Lifestyle Changes diet and the DASH Eating Plan.
- Weight Management. If you are overweight, losing weight can help lower your LDL (bad) cholesterol.
- Physical Activity. Everyone should get regular physical activity (30 minutes on most, if not all, days).
- Managing stress. Research has shown that chronic stress can sometimes raise your LDL cholesterol and lower your HDL cholesterol.
- Quitting smoking. Quitting smoking can raise your HDL cholesterol. Since HDL helps to remove LDL cholesterol from your arteries, having more HDL can help to lower your LDL cholesterol.
- Drug Treatment. If lifestyle changes alone do not lower your cholesterol enough, you may also need to take medicines. There are several types of cholesterol medicines available, including statins. The medicines work in different ways and can have different side effects. Talk to your health care provider about which one is right for you. While you are taking medicines to lower your cholesterol, you should continue with the lifestyle changes.
NIH: National Heart, Lung, and Blood Institute
What Your Cholesterol Levels Mean
Understanding your cholesterol levels
Maintaining healthy cholesterol levels is a great way to keep your heart healthy. It can lower your chances of getting heart disease or having a stroke.
But first, you have to know your cholesterol numbers.
The American Heart Association recommends
All adults age 20 or older should have their cholesterol (and other traditional risk factors) checked every four to six years. If certain factors put you at high risk, or if you already have heart disease, your doctor may ask you to check it more often. Work with your doctor to determine your risk for cardiovascular disease and stroke and create a plan to reduce your risk.
Learn how to get your cholesterol tested
Your test results: A preview
Your test results will show your cholesterol levels in milligrams per deciliter of blood (mg/dL). Your total cholesterol and HDL (good) cholesterol are among numerous factors your doctor can use to predict your lifetime or 10-year risk for a heart attack or stroke. Your doctor will also consider other risk factors, such as age, family history, smoking status, diabetes and high blood pressure.
Lipid profile or lipid panel is a blood test that will give you results for your HDL (good) cholesterol, LDL (bad) cholesterol, triglycerides and total blood (or serum) cholesterol.
Watch an animation about cholesterol score.
HDL (good) cholesterol
HDL cholesterol is called “good” cholesterol. A healthy HDL-cholesterol level may protect against heart attack and stroke. Your doctor will evaluate your HDL and other cholesterol levels and other factors to assess your risk for heart attack or stroke.
People with high blood triglycerides usually also have lower levels of HDL. Genetic factors, Type 2 diabetes, smoking, being overweight and being sedentary can all lower HDL cholesterol.
Women tend to have higher levels of HDL cholesterol than men do, but this can change after menopause.
LDL (bad) cholesterol
Since LDL is the bad kind of cholesterol, a low LDL level is considered good for your heart health.
LDL levels are one factor among many to consider when evaluating cardiovascular risk. Talk to your doctor about your LDL cholesterol level as well as other factors that impact your cardiovascular health.
A diet high in saturated and trans fat is unhealthy because it tends to raise LDL cholesterol levels.
Triglycerides are the most common type of fat in your body. They come from food, and your body also makes them.
Normal triglyceride levels vary by age and sex. People with high triglycerides often have a high total cholesterol level, including a high LDL (bad) cholesterol level and a low HDL (good) cholesterol level. Many people with metabolic syndrome or diabetes also have high triglyceride levels.
Factors that can contribute to elevated triglyceride levels:
- Overweight or obesity
- Insulin resistance or metabolic syndrome
- Diabetes mellitus, especially with poor glucose control
- Alcohol consumption, especially in excess
- Excess sugar intake, especially from processed foods
- High saturated fat intake
- Chronic kidney disease
- Physical inactivity
- Pregnancy (especially in the third trimester)
- Inflammatory diseases (such as rheumatoid arthritis, systemic lupus erythematosus
Some medications may also increase triglycerides.
Total blood (or serum) cholesterol
This part of your test results is a composite of different measurements. Your total blood cholesterol is calculated by adding your HDL and LDL cholesterol levels, plus 20% of your triglyceride level.
“Normal ranges” are less important than your overall cardiovascular risk. Like HDL and LDL cholesterol levels, your total blood cholesterol level should be considered in context with your other known risk factors.
Your doctor can recommend treatment approaches accordingly.
The new cholesterol guidelines: What you need to know – Harvard Health Blog
The new cholesterol guidelines from the American College of Cardiology and American Heart Association are out! These guidelines — last updated in 2013 — have been highly anticipated by the cardiology and broader medical community. They have been approved by a variety of additional professional societies, including the American Diabetes Association. Thus, the majority of physicians are very likely to follow them. So, what exactly is new and what do you need to know?
It starts with a healthy lifestyle, with statins for those who need them
A healthy diet and regular physical activity are recommended for all age groups as the foundation to prevent cardiovascular disease (CVD) and CVD risk factors such as high cholesterol.
However, once there is atherosclerotic cardiovascular disease (plaque in the arteries), the new guidelines recommend that high-intensity statin therapy or maximally tolerated statin therapy should be used, in addition to lifestyle modification, to reduce low-density lipoprotein cholesterol (LDL-C). For example, this recommendation applies to patients with a history of prior cardiovascular events such as heart attacks, or of procedures such as stenting. The goal is to lower LDL-C levels by 50% or more.
Cholesterol targets are back!
Much to the delight of physicians, concrete LDL-C targets have been reintroduced into this version of the guidelines. For individuals with atherosclerotic cardiovascular disease who are at very high risk of cardiac complications, drug therapy beyond statins is recommended to achieve a target LDL-C of 70 mg/dl.
The first addition beyond high-intensity statins would be the now generic ezetimibe, a cholesterol-lowering drug that works by preventing the absorption of cholesterol in the intestine. If that does not do the trick, the injectable PCSK9 inhibitors are considered a reasonable next step, with the caveat that the drugs are expensive and their long-term safety beyond three years is not well established. However, since the guidelines were finalized, one of the two companies that makes PCSK9 inhibitors has lowered the list price. This may ultimately help make these potent cholesterol reducing drugs more cost-effective.
The same algorithm as above is recommended for otherwise healthy people whose LDL-C is greater than or equal to 190 mg/dL. In this case, however, the target is 100 mg/dL instead of 70 mg/dL, presumably because there is no evidence (yet) of actual atherosclerosis.
In people 40 to 75 years of age with diabetes who have an LDL-C greater than or equal to 70 mg/dL, a moderate-intensity statin is recommended. If there are additional risk factors or the person is 50 years or older, then a high-intensity statin is considered reasonable.
The above recommendations are not controversial among expert physicians in the field. In fact, some may say that these guidelines are not aggressive enough in terms of wanting lower cholesterol targets in very high risk patients. But none who understand the data would disagree with the above guidelines as general starting points. If you have atherosclerotic cardiovascular disease, a very high cholesterol level, or diabetes, then, in addition to a healthy lifestyle, you really ought to be on a statin, assuming you can tolerate it, and maybe additional medications, depending on your cholesterol level.
What about healthy people with moderately elevated cholesterol levels?
What about healthy people who don’t fit into the above categories? The guidelines provide clear guidance, but things do get a bit more nuanced. Here, there really needs to be a discussion between the patient and their doctor.
Whether to start a statin or not depends on whether there are other cardiovascular risk factors, such as smoking, high blood pressure, or diabetes, and the actual LDL-C level. A family history of premature atherosclerotic cardiovascular disease would be another factor to consider, as might South Asian ethnicity or premature menopause (before age 40). Other blood test abnormalities, such as elevated triglycerides or elevated high-sensitivity C-reactive protein levels (a marker of inflammation), might also push towards starting someone on a statin. Another recommendation in the new guidelines is for potential use of coronary artery calcium (CAC) scans to decide whether or not to initiate statin therapy in select cases where the decision based on clinical risk factors is unclear. Patient preferences and cost (though most statins are now generic) are other potential issues to weigh. Online risk calculators may help.
Bottom line: If you are one of the large number of people who fall into this category, talk to your doctor about whether you should be on medications to lower your cholesterol, or whether lifestyle changes are enough.
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Know the Cholesterol Level That’s Right for You – And Stick to It
The National Lipid Association’s recommendations for how clinicians can help patients control their cholesterol levels focus on setting a personal goal based on your overall risk for cardiovascular disease.
Heart disease is the number one killer in the United States, and lipids — fats that circulate in your blood — are the primary cause. Recommendations published in the September 2014 issue of the Journal of Clinical Lipidology outline patient-specific ways to lower specific risks for potentially fatal cardiovascular events.
We spoke with NYU Langone Medical Center’s James A. Underberg, MD, director of the Bellevue Hospital Lipid Clinic in New York City and president of the National Lipid Association (NLA), about what the recommendations mean for patients and their families.
Everyday Health: According to the latest from the NLA, how often should you have your blood levels of cholesterol checked?
Dr. Underberg: For adults 20 or older, a good rule of thumb is every five years.
Everyday Health: When the blood test results come back, if your doctor tells you that you have dyslipidemia, what does that mean for your future?
Dr. Underberg: The way to understand it is as an abnormality in the lipid profile that puts you at risk for vascular disease or stroke. It can be abnormal triglycerides, not just cholesterol. The first step is to find out that there’s a problem. The second is to find the cause.
Everyday Health: What are the cutoff numbers that are considered normal for lipids?
Dr. Underberg: We describe these as desirable, rather than normal. Desirable levels of LDL cholesterol are under 100 milligrams per deciliter (mg/dL), and non-HDL cholesterol of under 130 mg/dL. These are the numbers to aim for.
In addition, HDL should be above 40 mg/dL for men, and above 50 mg/dL for women. And triglycerides should be below 150 mg/dL.
Everyday Health: Does a particular level mean you might have inherited high cholesterol, also known as familial hypercholesterolemia (FH)?
Dr. Underberg: The number that the NLA uses is an LDL cholesterol level above 190 mg/dL. This is in agreement with the American Heart Association and the American College of Cardiology. If your LDL is over 190, you need to be concerned about FH.
Everyday Health: Does this mean the other members of your family should get checked, too?
Dr. Underberg: Indeed, family members should get checked. Obviously your kids should get checked. Just as important, your siblings and your parents should, too. Call them up and get them checked. Ask them to get tested by someone who knows about FH. I say that screening should be north and south, east and west — across the family tree and across the United States.
Everyday Health: Why might your blood cholesterol target number, or goal, be a different number than another person’s?
Dr. Underberg: We decide based on two things. One, the inherent level of risk; and two, what the blood cholesterol level is. If cholesterol is low, but you have many risk factors — like smoking, diabetes, high blood pressure, or other heart disease — then your cholesterol goal is lower. On the other hand, if you have high cholesterol but fewer risk factors, your goal may be higher. It is not just putting the information into a calculator, but making it personal.
Everyday Health: If cholesterol levels don’t reach the goal, how do you know when it’s the right time to give medication a try — and what do you start with?
Dr. Underberg: We always like to give lifestyle interventions a really good try. Not for a few weeks, but for several months. If after three to four months the goal isn’t met, it may take reinforcement. See what’s working and make some changes. But if after one or two attempts you’re still not at goal and cholesterol is significantly above where it needs to be, then we recommend medication.
Statins are the first line of therapy. But not everyone can take a statin.
A woman thinking of getting pregnant would not want to be on a statin. And a person who had side effects from statins in the past also wouldn’t. But in some cases, you may require more than a statin, and may need another medication added to control cholesterol.
RELATED: 9 Hidden Heart Toxins and How to Avoid Them
Everyday Health: What are the risk factors within our control that, together with fat in the blood, increase the chances of having a heart attack or stroke?
Dr. Underberg: Some things we can’t control, like our age and our family medical history of heart disease. But the ones we can control include inactivity, smoking, obesity, and poor diet. These are in our own control. Sometimes treating other conditions may be helpful, too — for example if you have diabetes or high blood pressure. We need to think about the entire patient.
Everyday Health: What are the lifestyle changes NLA recommends to keep cholesterol levels down?
Dr. Underberg: We really focus on lifestyle, and have a second document coming out on diet. In the current recommendations, we focus on those interventions that have been shown to lower cholesterol. These are a diet restricted in saturated fat (found in butter, lard, meat, full-fat dairy, and coconut oil), weight loss, and referral to a registered dietician. If you also have diabetes, you’ll do better with a low-carb diet than a low-fat one.
Remember that clinical treatment guidelines are based on large groups of patients in clinical trials. But I still see patients one at a time who may not be the same as the people in those groups. That’s why personalization is so important.
Cholesterol test – Mayo Clinic
A complete cholesterol test — also called a lipid panel or lipid profile — is a blood test that can measure the amount of cholesterol and triglycerides in your blood.
A cholesterol test can help determine your risk of the buildup of plaques in your arteries that can lead to narrowed or blocked arteries throughout your body (atherosclerosis).
A cholesterol test is an important tool. High cholesterol levels often are a significant risk factor for coronary artery disease.
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Why it’s done
High cholesterol usually causes no signs or symptoms. A complete cholesterol test is done to determine whether your cholesterol is high and estimate your risk of developing heart attacks and other forms of heart disease and diseases of the blood vessels.
A complete cholesterol test includes the calculation of four types of fats (lipids) in your blood:
- Total cholesterol. This is a sum of your blood’s cholesterol content.
- High-density lipoprotein (HDL) cholesterol. This is called the “good” cholesterol because it helps carry away LDL cholesterol, thus keeping arteries open and your blood flowing more freely.
- Low-density lipoprotein (LDL) cholesterol. This is called the “bad” cholesterol. Too much of it in your blood causes the buildup of fatty deposits (plaques) in your arteries (atherosclerosis), which reduces blood flow. These plaques sometimes rupture and can lead to a heart attack or stroke.
- Triglycerides. Triglycerides are a type of fat in the blood. When you eat, your body converts calories it doesn’t need into triglycerides, which are stored in fat cells. High triglyceride levels are associated with several factors, including being overweight, eating too many sweets or drinking too much alcohol, smoking, being sedentary, or having diabetes with elevated blood sugar levels.
Who should get a cholesterol test?
Adults at average risk of developing coronary artery disease should have their cholesterol checked every five years, beginning at age 18.
More-frequent testing might be needed if your initial test results were abnormal or if you already have coronary artery disease, you’re taking cholesterol-lowering medications, or you’re at higher risk of coronary artery disease because you:
- Have a family history of high cholesterol or heart attacks
- Are overweight
- Are physically inactive
- Have diabetes
- Eat an unhealthy diet
- Smoke cigarettes
- Are a man older than 45 or a woman older than 55
People with a history of heart attacks or strokes require regular cholesterol testing to monitor the effectiveness of their treatments.
Children and cholesterol testing
For most children, the National Heart, Lung, and Blood Institute recommends one cholesterol screening test between the ages of 9 and 11, and another cholesterol screening test between the ages of 17 and 21.
If your child has a family history of early-onset coronary artery disease or a personal history of obesity or diabetes, your doctor might recommend earlier or more-frequent cholesterol testing.
Show more related information
There’s little risk in getting a cholesterol test. You might have soreness or tenderness around the site where your blood is drawn. Rarely, the site can become infected.
How you prepare
Generally you’re required to fast, consuming no food or liquids other than water, for nine to 12 hours before the test. Some cholesterol tests don’t require fasting, so follow your doctor’s instructions.
What you can expect
During the procedure
A cholesterol test is a blood test, usually done in the morning since you’ll need to fast for the most accurate results. Blood is drawn from a vein, usually from your arm.
Before the needle is inserted, the puncture site is cleaned with antiseptic and an elastic band is wrapped around your upper arm. This causes the veins in your arm to fill with blood.
After the needle is inserted, a small amount of blood is collected into a vial or syringe. The band is then removed to restore circulation, and blood continues to flow into the vial. Once enough blood is collected, the needle is removed and the puncture site is covered with a bandage.
The procedure will likely take a couple of minutes. It’s relatively painless.
After the procedure
There are no precautions you need to take after your cholesterol test. You should be able to drive yourself home and do all your normal activities. You might want to bring a snack to eat after your cholesterol test is done, if you’ve been fasting.
In the United States, cholesterol levels are measured in milligrams (mg) of cholesterol per deciliter (dL) of blood. In Canada and many European countries, cholesterol levels are measured in millimoles per liter (mmol/L). To interpret your test results, use these general guidelines.
|Total cholesterol(U.S. and some other countries)||Total cholesterol*(Canada and most of Europe)|
|Below 200 mg/dL||Below 5.2 mmol/L||Desirable|
|200-239 mg/dL||5.2-6.2 mmol/L||Borderline high|
|240 mg/dL and above||Above 6.2 mmol/L||High|
|LDL cholesterol(U.S. and some other countries)||LDL cholesterol*(Canada and most of Europe)|
|Below 70 mg/dL||Below 1.8 mmol/L||Best for people who have coronary artery disease — including a history of heart attacks, angina, stents or coronary bypass.|
|Below 100 mg/dL||Below 2.6 mmol/L||Optimal for people at risk of coronary artery disease or who have a history of diabetes. Near optimal for people with uncomplicated coronary artery disease.|
|100-129 mg/dL||2.6-3.3 mmol/L||Near optimal if there is no coronary artery disease. High if there is coronary artery disease.|
|130-159 mg/dL||3. 4-4.1 mmol/L||Borderline high if there is no coronary artery disease. High if there is coronary artery disease.|
|160-189 mg/dL||4.1-4.9 mmol/L||High if there is no coronary artery disease. Very high if there is coronary artery disease.|
|190 mg/dL and above||Above 4.9 mmol/L||Very high.|
|HDL cholesterol(U.S. and some other countries)||HDL cholesterol*(Canada and most of Europe)|
Below 40 mg/dL, men
Below 50 mg/dL, women
Below 1 mmol/L
Below 1.3 mmol/L
40-59 mg/dL, men
50-59 mg.dL, women
|60 mg/dL and above||Above 1.5 mmol/L||Best|
|Triglycerides(U.S. and some other countries)||Triglycerides*(Canada and most of Europe)|
|Below 150 mg/dL||Below 1.7 mmol/L||Desirable|
|150-199 mg/dL||1.7-2.2 mmol/L||Borderline high|
|200-499 mg/dL||2.3-5.6 mmol/L||High|
|500 mg/dL and above||Above 5.6 mmol/L||Very high|
*Canadian and European guidelines differ slightly from U.S. guidelines. These conversions are based on U. S. guidelines.
If your results show that your cholesterol level is high, don’t get discouraged. You might be able to lower your cholesterol with lifestyle changes, such as quitting smoking, exercising and eating a healthy diet.
If lifestyle changes aren’t enough, cholesterol-lowering medications also might help. Talk to your doctor about the best way for you to lower your cholesterol.
LDL Cholesterol – Understand the Test & Your Results
Sources Used in Current Review
Nordestgaard, Børge G., Langsted, Anne, Mora, Samia, et al. (2016 July 1). Fasting Is Not Routinely Required for Determination of a Lipid Profile: Clinical and Laboratory Implications Including Flagging at Desirable Concentration Cut-points—a Joint Consensus Statement from the European Atherosclerosis Society and European Federation of Clinical Chemistry and Laboratory Medicine. European Heart Journal. Available online at https://doi.org/10.1093/eurheartj/ehw152. Accessed September 2019.
Grundy, Scott M., Stone NJ, Bailey AL, et al. (2018 November 10) 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. Available online at https://www.ahajournals.org/doi/10.1161/CIR.0000000000000625. Accessed September 2019.
LDL: The “Bad” Cholesterol. U.S. National Library of Medicine. Available online at https://medlineplus.gov/ldlthebadcholesterol.html. Accessed September 2019.
Fernandez-Friera, L., Fuster, V., Lopez-melgar B. et al. (2017 December). Normal LDL-Cholesterol Levels Are Associated With Subclinical Atherosclerosis in the Absence of Risk Factors. Journal of the American College of Cardiology. Available online at http://www. onlinejacc.org/content/70/24/2979. Accessed September 2019.
Singh N., Kumar, B J, Thimmaraju, K V, et al. (2017 January). Anandaraja Formula or Friedewald Formula, which is a Better Formula for Calculating LDL Cholesterol in Comparison with Direct LDL – Measurement by Homogenous Assay Method. International Journal of Contemporary Medical Research. Available online at https://www.ijcmr.com/uploads/7/7/4/6/77464738/ijcmr_1228_feb_18.pdf. Accessed September 2019.
Krishnaveni, P., Gowda, V. (2015 December 1). Assessing the Validity of Friedewald’s Formula and Anandraja’s Formula For Serum LDL-Cholesterol Calculation. Journal of Clinical & Diagnostic Research. Available online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4717736/. Accessed September 2019.
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Thomas, Clayton L., Editor (1997). Taber’s Cyclopedic Medical Dictionary. F.A. Davis Company, Philadelphia, PA [18th Edition].
American Heart Association. What are healthy levels of cholesterol? Available online at http://22.214.171.124/presenter.jhtml?identifier=183.
National Heart, Lung, and Blood Institute of the National Institutes of Health, United States Department of Health and Human Services. Third report of the National Cholesterol Education Program (NCEP) Expert Panel on detection, evaluation, and treatment of high blood pressure in adults (Adult Treatment Panel III). Bethesda, Md. 2001 May. Available online at http://www.nhlbi.nih.gov/guidelines/cholesterol/atp3_rpt.htm.
American Heart Association. Numbers That Count for a Healthy Heart. Available online at http://www.americanheart.org.
Pagana K, Pagana T. Mosby’s Manual of Diagnostic and Laboratory Tests. 3rd Edition, St. Louis: Mosby Elsevier; 2006 pp 351-357.
National Heart, Lung, Blood Institute. National Cholesterol Education Program Guidelines, Cholesterol, ATP III (online information). Available online at http://www. nhlbi.nih.gov. Accessed February 2008.
Henry’s Clinical Diagnosis and Management by Laboratory Methods. 21st ed. McPherson R, Pincus M, eds. Philadelphia, PA: Saunders Elsevier: 2007.
Falko JM, Moser RJ, Meis SB, Caulin-Glaser T. Cardiovascular disease risk of type 2 diabetes mellitus and metabolic syndrome: focus on aggressive management of dyslipidemia. Curr Diabetes Rev. 2005 May;1(2):127-35.
Hayashi T, et. al. Importance of Lipid Levels in Elderly Diabetic Individuals—Baseline Characteristics and 1-Year Survey of Cardiovascular Events. Cir J 2008; 72:218—225.
American Academy of Pediatrics. 7 Jul 2008. AAP issues new guidelines on cholesterol screening (press release). Available online at http://www.aap.org/new/july08lipidscreening.htm. Accessed August 2008.
Pagana K, Pagana T. Mosby’s Manual of Diagnostic and Laboratory Tests. 4th Edition, St. Louis: Mosby Elsevier; 2010, Pp 356-363.
Van Leeuwen A.M., Poelhius-Leth, D.J. Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests With Nursing Implications. 3rd Edition, Philadelphia: F.A. Davis Company; 2009, Pp 325-329.
National Heart, Lung, and Blood Institute of the National Institutes of Health, United States Department of Health and Human Services. ATP III Update 2004: Implications of Recent Clinical Trials for the ATP III Guidelines. Bethesda, Md. 2004 May. Available online at http://www.nhlbi.nih.gov/guidelines/cholesterol/atp3upd04.htm.
(Updated 2011 August 2). Mayo Clinic. High Cholesterol [Online Information]. Available online at http://www.mayoclinic.com/health/high-blood-cholesterol/DS00178. Accessed August 2011.
(Updated 2010 May 23). MedlinePlus Medical Encyclopedia. LDL Test [Online information]. Available online at http://www.nlm.nih.gov/medlineplus/ency/article/003495.htm. Accessed August 2011.
Vujovic A, et al. Evaluation of Different Formulas for LDL-C Calculation. Lipids Health Dis, 2010; 9: 27. Abstract available online at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2847568/. Accessed Sept. 2011.
Davidson M, et al. Clinical Utility of Inflammatory Markers and Advanced Lipid Testing: Advice from an Expert Panel of Lipid Specialists. Journal of Clinical Lipidology 2011 Sep; 5(5): 338-67.
Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Sep 2002. PDF available for download at http://www.nhlbi.nih.gov/guidelines/cholesterol/atp3full.pdf. Accessed October 2012.
(©2012) American Heart Association. Cholesterol Levels. Available online at http://www.heart.org/HEARTORG/Conditions/Cholesterol/Cholesterol_UCM_001089_SubHomePage.jsp. Accessed October 2012.
(November 2012) American Association of Family Physicians. High Cholesterol. Available online at http://familydoctor.org/familydoctor/en/diseases-conditions/high-cholesterol.html. Accessed October 2012.
Kavey R-EW, et al. Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents: Summary report. Pediatrics 2011; 128: DOI:10.1542/peds.2009-2107C. PDF available for download at http://pediatrics.aappublications.org/site/misc/2009-2107.pdf. Accessed October 2012.
KidsHealth.org. Cholesterol and Your Child. Available online at http://kidshealth.org/parent/medical/heart/cholesterol.html#. Accessed October 2012.
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(2006) Sekar K. Increased Small Low-Density Lipoprotein Particle Number, A Prominent Feature of the Metabolic Syndrome in the Framingham Heart Study. Circulation. Available online at http://circ.ahajournals.org/content/113/1/20.full. Accessed October 2012.
(September 23, 2002) Blake G, et al. Low-Density Lipoprotein Particle Concentration and Size as Determined by Nuclear Magnetic Resonance Spectroscopy as Predictors of Cardiovascular Disease in Women. Circulation, Available online at http://circ.ahajournals.org/content/106/15/1930.full. Accessed October 2012.
Blakenstein R, et al. Predictors of Coronary Heart Disease Events Among Asymptomatic Persons With Low Low-Density Lipoprotein Cholesterol. Journal of the American College of Cardiology Volume 58, Issue 4, 19 July 2011, Pp 364–374.
Krauss R. Lipoprotein subfractions and cardiovascular disease risk. Curr Opin Lipidol 2010 Aug;21(4):305-11. Abstract available online at http://www.ncbi.nlm.nih.gov/pubmed/20531184. Accessed October 2012.
Prado K, et al. Low-density lipoprotein particle number predicts coronary artery calcification in asymptomatic adults at intermediate risk of cardiovascular disease. J Clin Lipidol 2011 Sep-Oct;5(5):408-13. Abstract available online at http://www.ncbi.nlm.nih.gov/pubmed/21981843. Accessed October 2012.
(May 2012) Lavie C, et.al. To B or Not to B: Is Non–High-Density Lipoprotein Cholesterol an Adequate Surrogate for Apolipoprotein B? Mayo Clin Proc. 2010 May; 85(5): 446–450. Available online at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2861974/. Accessed October 2012.
(2016 March 23 Updated). Good vs. Bad Cholesterol. American Heart Association. Available online at http://www.heart.org/HEARTORG/Conditions/Cholesterol/AboutCholesterol/Good-vs-Bad-Cholesterol_UCM_305561_Article.jsp#.Vy9hEXq9b5M. Accessed on 5/01/16.
Stone N.J. et al. (2013 November 12). 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults. Circulation 10.1161/01.cir.0000437738.63853.7. Available online at https://circ. ahajournals.org/content/early/2013/11/11/01.cir.0000437738.63853.7a. Accessed on 5/01/16.
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(2016 March 28 Updated). About Cholesterol. American Heart Association. Available online at http://www.heart.org/HEARTORG/Conditions/Cholesterol/AboutCholesterol/About-Cholesterol_UCM_001220_Article.jsp#.Vy9WX3q9b5M. Accessed on 5/01/16.
Hughes, S. (2015 November 13 Updated). Focus More on % LDL Reductions: New JUPITER Data. Medscape Multispecialty from American Heart Association (AHA) 2015 Scientific Sessions. Available online at http://www.medscape.com/viewarticle/854491. Accessed on 5/01/16.
Lloyd-Jones DM, Morris PB, Ballantyne CM, Birtcher KK, Daly Jr DD, DePalma SM, Minissian MB, Orringer CE, Smith SC. 2016 ACC expert consensus decision pathway on the role of non-statin therapies for LDL-cholesterol lowering in the management of atherosclerotic cardiovascular disease risk: a report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents. J Am Coll Cardiol 2016. Available as pdf at http://content.onlinejacc.org/article.aspx?articleID=2510936#tab1.
90,000 RCO considers an aggressive approach in the treatment of dyslipidemia more effective
New clinical guidelines for the treatment of dyslipidemia were presented at the Congress of the European Society of Cardiology ESC-2019 in Paris in early September. One of the main innovations: the recommendation to achieve the target values of LDL-C by a combination of high doses of statins with the possibility of adding ezetimibe and PCSK9 inhibitors if necessary. For high and very high risk patients, the maximum reduction in LDL cholesterol is recommended.
“The more stringent target LDL-C levels (for most patients less than 1.4 mmol / L) are close to the latest Russian recommendations for the treatment of dyslipidemia, where a target level of less than 1.5 mmol / L is recognized. For the very high risk category, an even lower level was deemed appropriate, which is not in our recommendations. These values are based on the results of those studies that show that lower lipid levels are associated with better survival, ”said Deputy Director General for Research and Preventive Cardiology of the National Medical Research Center of Cardiology of the Ministry of Health of Russia, Professor Nana Pogosova .
A further decrease in the level of LDL-C leads to an additional decrease in the incidence of cardiovascular complications in patients of high and very high risk categories: those who have had acute coronary syndrome, diabetes mellitus, etc. M.V. Lomonosov, member of the European Heart Failure Association, Professor Simon Matskeplishvili . For example, in Russian and American recommendations for the treatment of patients with coronary heart disease and diabetes mellitus, the target level of 1.5 mmol / L for such an extremely high risk category has been in effect for several years.
“There were certain fears that a significant decrease in cholesterol could cause some side effects in the form of neurodegenerative conditions, diabetes mellitus, cancer. But, as studies with PCSK9 inhibitors have shown, in which extremely low LDL-C concentrations were achieved up to 0.5 mmol / L, this does not lead to any significant complications or side effects, while additionally and significantly reducing the risk of adverse cardiovascular events. Therefore, taking advantage of the fact that today there is an opportunity for a more significant and, most importantly, safe reduction of cholesterol, we adhere to the concept: the lower the better, ”he stressed.
In parallel with this, the ESC “relaxed” the recommendations for the age group over 75 years old. In elderly patients at high and very high risk, statins for primary prevention are recommended to start at a low dose (if there is significant renal impairment and / or there is a potential for drug interactions), then titrate the dose upward until the target LDL-C is reached.
“This is a fairly balanced approach to prescribe statins not to everyone, but only to those who have an increased risk, it is high or very high, justified from the point of view of preventing complications.There is a position that statins should be prescribed to everyone indiscriminately from a certain age. But still, in most European countries, this concept did not find supporters and was not accepted. That is, an individualized strategy prevails: first, an examination is prescribed to determine the total cardiovascular risk, and only on the basis of its results, lipid-lowering drugs are recommended or not, ”Nana Pogosova clarified.
The effectiveness of cholesterol lowering in primary prevention in older patients is not as evident as in younger patients or in secondary prevention.Therefore, a softer approach has been adopted, explained Professor Matskeplishvili: “In older patients, the potential risk of side effects is slightly higher, so we prescribe these drugs with caution, based on the fact that it is better to stay at a well-tolerated dose and not to lower cholesterol too aggressively. At the same time, achieve better adherence to treatment. ”
In addition, according to him, the positive properties of statins are not limited only to lowering cholesterol. They have a rather pronounced anti-inflammatory effect, improve endothelial function, stabilize atherosclerotic plaques in the coronary arteries, destabilization of which with subsequent thrombosis and causes acute coronary syndromes.“Therefore, the positive, or as we call them, pleiotropic, properties of these drugs are much more, they are conceived more pronounced than a simple decrease in cholesterol,” he said. That is why statins are indicated for absolutely all patients with coronary heart disease, and not only for those with high cholesterol.
It is extremely important to understand that recommendations for achieving target levels and actual clinical practice are not always the same, emphasized Simon Matskeplishvili: blood test.After all, we treat not pieces of paper with numbers, but people. For example, even if the achieved level is slightly higher than the target, but at the same time I see that the patient is doing everything possible and recommended to maintain his health, I tend to not intensify and complicate the therapy if the clinical situation allows it. For example, if the target LDL level is 1.8 mmol / L, and the patient has 2 mmol / L, and at the same time he tolerates the maximum dose of statins, I seriously think before adding ezetimibe or PCSK9 inhibitors, ”he concluded.
Achieving the target level of low-density lipoprotein cholesterol: current opportunities | Kotovskaya Yu.V., Eruslanova E.A.
The review provides an analysis of the main characteristics, clinical efficacy and safety of fixed combinations of modern lipid-lowering drugs, shows the prospects for combination therapy using ezetimibe
Target LDL-C levels in current guidelines
Cardiovascular diseases (CVD) rank first among the causes of morbidity and mortality worldwide .Reducing the level of low-density lipoprotein cholesterol (LDL-C) with the use of HMG-CoA reductase inhibitors is the cornerstone of primary and secondary prevention of adverse cardiovascular outcomes [2–8]. According to the 2019 European Society of Cardiology guidelines, patients with dyslipidemia are advised to prescribe a high-intensity statin (for example, atorvastatin or rosuvastatin), which provides the necessary reduction in LDL-C levels, and to increase the dose to the maximum tolerated level in order to achieve the target LDL-C levels established depending on risk groups (tab. 12). Target LDL-C levels depending on cardiovascular risk and the algorithm for achieving them are presented in Figures 1 and 2. In some patients, despite the use of high doses of even high-intensity statins, it is not possible to achieve target LDL-C levels during monotherapy. Even with the proof of the thesis “the lower the level of LDL-C, the lower the risk of cardiovascular morbidity and mortality”, despite the existence of clear clinical recommendations, the indicators of achieving the target LDL-C among patients taking statins are 33.7%, while in those receiving statins for secondary prevention, 58%  and need combination therapy with ezetimibe [11–15].Taking a fixed combination of a statin and ezetimibe increases the effectiveness of each drug in a pair (due to a synergistic effect), increases adherence to therapy and, in some cases, may be more economically beneficial for the patient . The purpose of this review is to analyze the main characteristics, clinical efficacy and safety of fixed combinations of modern lipid-lowering drugs to increase the ability to achieve the target LDL-C level in accordance with current recommendations.
Simvastatin and ezetimibe
The first fixed combination of a statin and ezetimibe was a simvastatin-based combination. Simvastatin 10–40 mg / day reduces LDL-C levels by 18–41% less than atorvastatin or rosuvastatin , which limits its use in cases where it is required to achieve modern target LDL-C values.The bioavailability of simvastatin is about 5%, the half-life is about 1-3 hours . In general, the drug is well tolerated, an increase in the level of hepatic transaminases occurs in 1% of patients .
Ezetimibe lowers LDL-C levels by blocking the absorption of cholesterol in the small intestine and increasing the excretion of cholesterol in the bile. Many studies have repeatedly demonstrated the synergistic effect of prescribing drugs from the class of statins and ezetimibe [22-24].
The effectiveness of ezetimibe and simvastatin therapy was shown in the randomized, double-blind, placebo-controlled study IMProved Reduction of Outcomes: Vytorin Efficacy International Trial (IMPROVE-IT).The study design was based on a comparison of simvastatin monotherapy (40 mg) and combination therapy with simvastatin and ezetimibe (40 + 10 mg) in patients after myocardial infarction. In the combination therapy group, the achieved LDL-C level was significantly lower (53.7 mg / dL versus 69.5 mg / dL in the monotherapy group). A decrease in the number of heart attacks and strokes was also demonstrated in the combination therapy group (p <0.05) . Also interesting are the results of a 2017 study, which showed that the protective effect of combination therapy was higher in the group with GFR less than 45 ml / min / 1.73m 2 .
Simultaneous administration of simvastatin and ezetimibe did not increase the risk of developing side effects of statins – myopathy and increased levels of hepatic transaminases . Moreover, it has been shown that the combination does not increase the risk of developing type 2 diabetes mellitus, which is sometimes observed with therapy with high doses of statins [28, 29].
Atorvastatin and ezetimibe
Atorvastatin at a dose of 10–80 mg / day reduces the level of LDL-C by 37–51%, reduces the risk of developing cardiovascular and cerebrovascular complications, has demonstrated its effectiveness in conducting both primary and secondary prevention in a series of clinical studies and meta-analyzes [30 ].
A meta-analysis that included 17 studies showed that combination therapy with atorvastatin and ezetimibe reduced LDL-C and triglycerides and increased HDL-C (p <0.05) . Combination therapy has demonstrated a decrease in coronary atherosclerosis, as measured by intravascular ultrasound, compared with atorvastatin alone . Studies have shown a comparable incidence of adverse reactions in combination therapy with atorvastatin and ezetimibe and monotherapy with atorvastatin or ezetimibe, with isolated cases of increased hepatic transaminase levels, the development of myopathy or intestinal irritation .
Rosuvastatin and ezetimibe
Rosuvastatin at a dose of 5-40 mg / day lowers the level of LDL-C by 46-55%, the average decrease in cholesterol and LDL-C is higher than that of other drugs from this group in an equivalent dosage. The bioavailability of rosuvastatin is 20% (comparable to the bioavailability of atorvastatin), the half-life is 19 hours. Most of the drug is excreted in the bile (72%), the remainder in the urine. The drug is not metabolized by the liver cytochrome system, and therefore practically does not interact with other drugs.Side effects such as myopathy and rhabdomyolysis are rare (less than 0.1% and less than 0.01%, respectively) .
The efficacy and safety of rosuvastatin was demonstrated in the study The Justification for the Use of statins in Prevention: an International Trial Evaluating Rosuvastatin (JUPITER) trial . The appointment of rosuvastatin reduced the risk of heart attack, stroke, the need for revascularization and hospitalization for unstable angina pectoris, as well as the risk of death from all causes by 44% compared with placebo (p <0.00001).The results of the HOPE-3 (Heart Outcomes Prevention Evaluation 3) study showed that treatment with rosuvastatin compared with placebo reduced the risk of cardiovascular complications in patients from the middle risk group, while only antihypertensive therapy (candesartan) compared with placebo did not lead to risk reduction . Compared with simvastatin and atorvastatin, the use of rosuvastatin already at a dose of 10 mg is superior to simvastatin at a maximum dose of 40 mg and is equivalent to the use of atorvastatin 40 mg in its ability to reduce LDL-C .
The effectiveness of the combination of rosuvastatin with ezetimibe was demonstrated in a study that included 469 patients at high risk of CVD, who for 6 weeks. received either monotherapy with rosuvastatin (40 mg) or combined therapy with rosuvastatin and ezetimibe (40 + 10 mg). Combination therapy showed an additional 12% reduction in LDL-C levels compared to monotherapy (-69.8% versus -57.1%). Moreover, patients in the combination therapy group were more likely to achieve target LDL-C levels.For example, in the very high-risk group, 79.6% of participants achieved the target values (LDL-C less than 70 mg / dL), while in the monotherapy group it was possible only in 35% of cases .
The safety and efficacy of the combination drug (ezetimibe 10 mg and rosuvastatin 5, 10 or 20 mg) was demonstrated in The Multiceneter Randomized Study of Rosuvastatin and Ezetimibe (MRS-ROSE). The study compared the efficacy of the combined drug with the efficacy of rosuvastatin monotherapy for 8 weeks.Depending on the dose of rosuvastatin in the combined preparation, the level of LDL-C decreased by 56–63%, which exceeded the effectiveness of rosuvastatin monotherapy at the same dosage. In addition, in patients with diabetes mellitus or metabolic syndrome, there was a more significant reduction in LDL-C, triglycerides and total cholesterol levels among those receiving therapy with the combination drug .
The Ildong Rosuvastatin & Ezetimibe for Hypercholestelomia (I-ROSETTE) study showed that the safety and tolerability of the combination therapy was comparable to that of rosuvastatin monotherapy .
Higher efficacy and favorable safety profile of combination therapy with rosuvastatin and ezetimibe compared with increasing the dose of rosuvastatin were shown in a multicenter, randomized, double-blind study conducted in the Americas and Europe. 440 study participants were divided into 2 parallel groups (depending on the dosage of rosuvastatin), each of which, in turn, was also divided into 2 groups: taking the combined drug or increasing the dose of rosuvastatin (from 5 to 10 mg or from 10 to 20 mg , and in combination therapy, the statin dose remained the same).The target LDL-C level from 70 to 100 mg / dL was reached by 59. 4% of patients receiving combination therapy, and only 30.9% with increasing doses of rosuvastatin .
In January 2019, the first fixed combination drug of rosuvastatin and ezetimibe Rosulip® Plus was registered in Russia. Rosulip® Plus is indicated in addition to the diet of patients with primary hypercholesterolemia (with the exception of heterozygous familial hypercholesterolemia). Rosulip Plus is prescribed as a substitution therapy for patients whose lipid profile was adequately controlled by the simultaneous use of separate preparations of rosuvastatin and ezetimibe in doses equivalent to the corresponding doses in a fixed combination.
Prospects for combination therapy with ezetimibe
Bempedoic acid is a new generation lipid-lowering drug that can lower LDL-C levels by 40%. Bempedoic acid is a prodrug that is converted in the liver to bempedoic acetyl coenzyme A, which is an inhibitor of the enzyme ATP citrate lipase. In accordance with its mechanism of action, this drug not only lowers the level of LDL-C, but also blocks the synthesis of fatty acids [40–42].
The combination of bempedoic acid (120 or 180 mg / day) and ezetimibe (10 mg / day) in patients with statin intolerance and in those who could receive statin therapy led to a decrease in LDL-C levels by 43.1% and 47.7 %, respectively, depending on the dosage of the drug. Monotherapy with bempedoic acid reduces LDL-C levels by 27.5% and 30.1% (corresponding to the indicated dose) and is well tolerated . In a phase III clinical trial, the addition of this drug to statin and ezetimibe therapy in patients with high and very high CVD risk reduced LDL-C levels by 28% and the CVD risk by 33% .The combination of bempedoic acid and ezetimibe continues to be explored as a promising combination.
Ezetimibe is often used as a second drug to achieve target LDL-C levels. The combination of statins and ezetimibe has been conclusively proven to be effective and safe. In the light of the updated recommendations of the European Society of Cardiology 2019, combination therapy with rosuvastatin and ezetimibe is receiving special attention due to the decrease in the recommended target values of LDL-C in patients with a very high risk of less than 1.4 mmol / L and a decrease in the level of LDL-C by 50% or more …Studies have shown that the combination of a high-intensity statin (such as rosuvastatin) and ezetimibe lowers LDL levels by an average of 65% from baseline . Achieving the target LDL values will reduce the risk of cardiovascular complications, and the visible result will increase patient adherence to therapy.
New generation drugs based on bempedoic acid show promising results in lowering LDL-C levels both in monotherapy and in combination with other drugs (for example, with ezetimibe) and are interesting from the point of view of expanding the possibilities of achieving target LDL-C in patients who are not can take statins for a variety of reasons.Fixed combinations of lipid-lowering drugs can reduce the frequency of undesirable side reactions (for example, it has already been proven that when ezetimibe is taken together with statins, the risk of diabetes mellitus is reduced), due to the synergistic effect, a more significant decrease in LDL-C and the risk of cardiovascular complications is noted, moreover, adherence to long-term lipid-lowering therapy is significantly increased.
CLINICAL OUTCOMES OF PATIENTS WITH STABLE SENOCARDIA AFTER ROUTINE PERCUTANEOUS CORONARY INTERVENTION WITH COATING STENT IMPLANTATION | Tomilova
1.Bibek S, Xie Y, Gao J et al. Role of Pre-procedural C-reactive Protein Level in the Prediction of Major Adverse Cardiac Events in Patients Undergoing Percutaneous Coronary Intervention: a Meta-analysis of Longitudinal Studies. Inflammation 2015; 38 (1): 159-169.
2. Chazov EI, Karpov YuA. Rationale Pharmacotherapy For Cardiovascular Diseases. A guidebook for medical practitioners. Moscow Litterra Publishers 2014; 1056 p.Russian (Chazov E.I., Karpov Yu.A. Rational pharmacotherapy of cardiovascular diseases. A guide for practicing physicians. Moscow: Litterra 2014; 1056 p).
3. Cholesterol Treatment Trialists’ (CTT) Collaborators, Mihaylova B, Emberson J et al. The effects of lowering LDL cholesterol with statin therapy in people at low risk of vascular disease: meta-analysis of individual data from 27 randomized trials.Lancet 2012; 380: 581-590.
4. ESC / EAS Guidelines for the management of dyslipidaemias. European Heart Journal 2011; 32: 1769-1818.
5. Kukharchuk VV, Konovalov GA, Susekov AV et al. Diagnostics and correction of lipid metabolism disorders in order to prevent and treat atherosclerosis. Russian recommendations V revision. Atherosclerosis 2012; 2 (8): 61-94.
6. Stone NJ, Robinson J, Lichtenstein AH et al. 2013 ACC / AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology / American Heart Association Task Force on Practice Guidelines. Circulation 2013; 00: 000–000.
7. Di Sciascio G, Patti G, Pasceri V et al.Atorvastatin for Reduction of Myocardial Damage During Angioplasty (Efficacy of atorvastatin reload in patients on chronic statin therapy undergoing percutaneous coronary intervention: results of the ARMYDA RECAPTURE (Atorvastatin for Reduction of Myocardial Damage During Angioplasty) Randomized Trial. J Am Coll Cardiol 2009; 54: 54: 558-565.
8. Ndrepepa G, Braun S, Tada T et al. Comparative prognostic value of low-density lipoprotein cholesterol and C-reactive protein in patients with stable coronary artery disease treated with percutaneous coronary intervention and chronic statin therapy.Cardiovasc Revasc Med. 2014; 15 (3): 131-136.
9. Puri R, Nissen SE, Libby P et al. C-reactive protein, but not low-density lipoprotein cholesterol levels, associate with coronary atheroma regression and cardiovascular events after maximally intensive statin therapy. Circulation 2013; 128 (22): 2395-2403.
10. Boytsov SA, Khomitskaya YuV.Centralised Survey on the Undertreatment of the Hypercholesterolemia in Russia (CEPHEUS). Cardiovascular Therapy and Prevention 2013; 12 (4): 67–74 (Boytsov SA, Khomitskaya YuV. Centralized study to evaluate the effectiveness of treatment of hypercholesterolemia in Russia (CEPHEUS). Cardiovascular therapy and prevention, 2013; 12 (4): 67–74).
11. Yao HM, Wan YD, Zhang XJ et al. Long-term follow-up results in patients undergoing percutaneous coronary intervention (PCI) with drug-eluting stents: results from a single high-volume PCI center.BMJ Open 2014; 4: e004892.
12. Zahn R, Neumann FJ, Buttner HJ et al. Long-term follow-up after coronary stenting with the sirolimus-eluting stent in clinical practice: results from the prospective multi-center German Cypher Stent Registry. Clin Res Cardiol 2012; 101: 709-716.
13. Akhmedzhanov NM, Nebieridze DV, Safaryan AS et al.Analysis of hypercholesterolemia prevalence in the outpatient practice (according to the ARGO study): Part I. Rational Pharmacotherapy in Cardiology 2015; 11 (3): 253-260 (Akhmedzhanov NM, Nebieridze DV, Safaryan AS et al. Analysis of the prevalence of hypercholesterolemia in conditions outpatient practice (according to the ARGO study): part I. Rational Pharmacotherapy in Cardiology 2015; 11 (3): 253-260).
14. Goodman SG, Langer A, Bastien NR et al.Prevalence of dyslipidemia in statin-treated patients in Canada: results of the DYSlipidemia International Study (DYSIS). Can J Cardiol 2010; 26 (9): 330-335.
15. Gitt AK, Junger C, Smolka W et al. Prevalence and overlap of different lipid abnormalities in statin-treated patients at high cardiovascular risk in clinical practice in Germany. Clin Res Cardiol 2010; 99 (11): 723-733.
90,000 Comparison of two target LDL cholesterol levels after ischemic stroke
The aim of this study was to evaluate target low-density lipoprotein (LDL-C) cholesterol levels for reducing cardiovascular events after stroke or TIA.A total of 2860 patients in France and South Korea were randomized to target LDL-C levels of <1.8 mmol / L or 2.3-2.8 mmol / L. All patients had either ischemic stroke within the previous 3 months or TIA within the previous 15 days. All of them were treated with statins, ezetimibe, or a combination thereof and showed signs of cerebrovascular disease or coronary artery disease. The patients were followed up for 3.5 years. The average LDL-C level achieved was 1.7 mmol / L in the group with the lower target level and 2.5 mmol / L in the group with the higher target level.The primary endpoint of major cardiovascular events occurred in 8.5% of patients in the lower target group and 10.9% in the higher target group (OR 0. 78; p = 0.04) …
Patients with atherosclerosis after ischemic stroke or TIA who had a target LDL cholesterol level of less than 1.8 mmol / L had a lower risk of subsequent cardiovascular events than those whose LDL-cholesterol target range was 2.3- 2.8 mmol / l.
BACKGROUND FOR THE RESEARCH
The use of intensive lipid-lowering therapy with statins is recommended after transient ischemic attack (TIA) and ischemic stroke of atherosclerotic genesis.The target level of low-density lipoprotein cholesterol (LDL-C) for reducing cardiovascular events after stroke is not well understood.
In a parallel group study conducted in France and South Korea, the authors randomly assigned patients with ischemic stroke in the previous 3 months or TIA in the previous 15 days to target LDL-C levels of less than 1.8 mmol / L (lower target level) or a target level in the range of 2.3-2.8 mmol / L (the group with the higher target level).All patients showed signs of cerebrovascular or coronary atherosclerosis and received statin, ezetimibe, or both. The combined primary endpoint of major cardiovascular events included ischemic stroke, myocardial infarction, new symptoms leading to urgent coronary or carotid revascularization, or death from cardiovascular causes.
A total of 2860 patients were enrolled and followed up for 3.5 years; 1430 were assigned to each group.The mean LDL cholesterol at inclusion was 3.5 mmol / L, and the mean achieved LDL cholesterol was 1.7 mmol / L in the lower LDL-cholesterol target group and 2.5 mmol / L in the higher target group. LDL-cholesterol level. The study was halted after 277 of the estimated 385 endpoint events occurred. The combined primary endpoint occurred in 121 patients (8.5%) in the lower LDL-C target group and 156 (10.9%) in the higher target group (adjusted hazard ratio 0.78; 95 % confidence interval 0. 61-0.98; p = 0.04).The incidence of intracranial hemorrhage and newly diagnosed diabetes mellitus did not differ significantly between the two groups.
Patients with atherosclerosis after ischemic stroke or TIA who had a target LDL cholesterol level of less than 1.8 mmol / L had a lower risk of subsequent cardiovascular events than those whose target LDL-cholesterol range was 2.3-2 , 8 mmol / l.
90,000 How much is it necessary to reduce the level of LDL-C after a stroke?
Current guidelines for the management of patients with ischemic stroke include an “intensive” regimen of lipid-lowering therapy, but precise target levels are often not specified.In this connection, the Treat Stroke to Target study tested the hypothesis of the advantage of a more intense [target level of low density lipoprotein cholesterol (LDL-C)] <1.8 mmol / L) lipid-lowering therapy regimen over a less intense (target level of LDL-C - 2.3- 2.8 mmol / L) in relation to reducing the risk of cardiovascular events in patients with ischemic stroke or transient ischemic attack (TIA) and with proven atherosclerotic lesion.
The randomized study, conducted in France and South Korea, included patients who had an ischemic stroke 3 months before inclusion or TIA 15 days.In addition, a prerequisite for inclusion was the presence of atherosclerotic vascular lesions, defined as intra- or extracranial stenosis of the cerebral artery, ipsi- or contralateral in relation to the focus of brain damage; the presence of an atherosclerotic plaque in the aortic arch, at least 4 mm in size or coronary heart disease.
Patients were randomized 1: 1 to two regimens of lipid-lowering therapy with target LDL-C levels of <1.8 mmol / L and 2. 3-2.8 mmol / l. To achieve these levels of LDL-C, it was planned to use a statin and, if necessary, ezetimibe.
The combined primary endpoint included ischemic stroke, myocardial infarction, recurrent symptoms requiring coronary or carotid revascularization, and death from cardiovascular causes.
A total of 2860 patients were included in the study, with an average follow-up period of 3.5 years.
It should be noted that the study was stopped ahead of schedule for administrative reasons. By the time of completion, there were 277 cases of the onset of the primary endpoint (it was planned to complete the study with the onset of 385 outcomes).
The incidence of the primary endpoint was 8.5% in the intensive group and 10.9% in the comparison group (adjusted hazard ratio 0.78; 95% confidence interval 0.61-0.98; p = 0.04).
Among adverse events, taking into account the increased risk of hemorrhagic stroke found in observational studies with low LDL-C, the frequency of its occurrence in groups of different intensity regimens of lipid-lowering therapy was estimated. Thus, hemorrhagic stroke was registered in 18 (1.3%) patients from the intensive regimen and in 13 (0.9%) from the comparison group (hazard ratio 1.38; 95% confidence interval 0.66-2.82). The incidence of the secondary endpoint, which included primary + hemorrhagic stroke, was 133/1430 in the intensive group and 165/1430 in the comparison group (hazard ratio 0.80; 95% confidence interval 0.63-1). There was no significant increase in the incidence of diabetes mellitus in the intensive care group.
Thus, in patients with stroke or TIA with confirmed atherosclerosis, more intense lipid-lowering therapy leads to a lower incidence of major cardiovascular events than a less intense regimen.
The results of the presented study are likely to have an impact on the recommended target level of LDL-C for patients with stroke or TIA.
1. Amarenco P, Kim J, Labreuche J, Charles H, Abtan J, Bejot Y, et. al. N Engl J Med. 2019. DOI: 10.1056 / NEJMoa1910355.
Total cholesterol (cholesterol) is a fat-like substance that the body needs for the normal functioning of cells, digestion of food, and the creation of many hormones.Too much cholesterol (cholesterol) increases the risk of plaque in the arteries, which can block them and cause a heart attack or stroke.
Blood cholesterol, Cholesterol, Chol, Cholesterol total.
Colorimetric photometric method.
Mmol / L (millimol per liter).
What biomaterial can be used for research?
Venous, capillary blood.
How to properly prepare for the study?
- Do not eat for 12 hours before testing.
- Eliminate physical and emotional stress 30 minutes before the study.
- Do not smoke within 30 minutes prior to examination.
General information about the study
Cholesterol (cholesterol, cholesterol) is a fat-like substance vital for the body.The correct scientific name for this substance is “cholesterol” (the ending “-ol” indicates that it belongs to alcohols), however, the name “cholesterol” has become widespread in the mass literature, which we will use later in this article. Cholesterol is involved in the formation of cell membranes in all organs and tissues of the body. On the basis of cholesterol, hormones are created that are involved in the growth, development of the body and the implementation of the reproduction function. Bile acids are formed from cholesterol, which are part of bile, thanks to which fats are absorbed in the intestines.
Cholesterol is insoluble in water, therefore, to move through the body, it is “packed” in a protein shell, consisting of special proteins – apolipoproteins. The resulting complex (cholesterol + apolipoprotein) is called lipoprotein. Several types of lipoproteins circulate in the blood, differing in the proportions of their constituent components:
- very low density lipoprotein (VLDL),
- low density lipoprotein (LDL),
- high density lipoprotein (HDL).
LDL cholesterol and VLDL cholesterol are considered “bad” types of cholesterol, since they contribute to the formation of plaques in the arteries, HDL cholesterol, on the contrary, is called “good”, since HDL removes excess cholesterol.
The total cholesterol (cholesterol) test measures the total amount of cholesterol (both “bad” and “good”) circulating in the blood as lipoproteins.
The liver produces a sufficient amount of cholesterol for the body’s needs, but some of it comes from food, mainly meat and fatty dairy products.If a person has a hereditary predisposition to high cholesterol or eats too much cholesterol-containing food, then the level of cholesterol in the blood can rise and cause harm to the body. Excess cholesterol is deposited in the walls of blood vessels in the form of plaques, which can restrict the movement of blood through the vessel, and also make the vessels more rigid (atherosclerosis), which significantly increases the risk of heart disease (coronary artery disease, heart attack) and stroke.
What is the research used for?
- To assess the risk of atherosclerosis and heart problems.
- For the prevention of many diseases.
When is the study scheduled?
- At least once every 5 years for all adults over 20 years of age (usually included in the list of standard set of tests for preventive examinations).
- Together with analyzes for LDL cholesterol, VLDL cholesterol, HDL cholesterol, triglycerides and with a coefficient of atherogenicity, this is the so-called lipidogram.
- Several times a year if a diet restricted to animal fats is prescribed and / or cholesterol-lowering medications are taken (to check if a person is reaching target cholesterol levels and thus reducing their risk of cardiovascular disease).
- If one or more risk factors for cardiovascular disease are present in the patient’s life:
- a certain age period (men over 45 years old, women over 55 years old),
- high blood pressure (140/90 mm Hg and above),
- increased cholesterol levels or cardiovascular disease in other family members (heart attack or stroke in a close male relative under 55 years of age or a female under 65 years of age),
- ischemic heart disease,
- suffered a heart attack or stroke,
- diabetes mellitus,
- alcohol abuse,
- eating large amounts of food containing animal fats,
- low physical activity.
- At 2-10 years old, a child in whose family someone had heart disease at a young age or high cholesterol.
What do the results mean?
Reference values (cholesterol norm):
The concept of “norm” is not quite applicable in relation to the level of total cholesterol. For different people with different numbers of risk factors, cholesterol levels will differ. The test for total cholesterol (cholesterol) is used to determine the risk of cardiovascular disease, however, in order to determine this risk for a particular patient most accurately, it is necessary to assess all the predisposing factors.
According to clinical guidelines, 1 the calculation of individual risk is carried out using the SCORE scale (Systematic Coronary Risk Evaluation).
“Diagnostics and correction of lipid metabolism disorders for the prevention and treatment of atherosclerosis. Russian recommendations, VII revision. 2020”.
“2019 ESC / EAS Guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk”.
Causes of increased total cholesterol level (hypercholesterolemia)
Hypercholesterolemia can be the result of a hereditary predisposition (familial hypercholesterolemia) or excessive intake of animal fats with food.In most people with high cholesterol, both are involved to some extent.
Cholesterol level is only one of the risk factors for cardiovascular diseases. The overall assessment of this risk is carried out taking into account all parameters, including the presence of cardiovascular diseases in the patient or his relatives, smoking, high blood pressure, diabetes mellitus, obesity, etc. For patients who have such factors, the target levels of total cholesterol are lower 4 mmol / L.To more accurately determine the risk of cardiovascular disease, a low-density lipoprotein cholesterol (LDL-C) test is prescribed.
Before the appointment of treatment, it is necessary to exclude other causes of an increase in total cholesterol:
- cholestasis – stagnation of bile, which can be caused by liver disease (hepatitis, cirrhosis) or gallstones,
- Chronic kidney inflammation leading to nephrotic syndrome,
- chronic renal failure,
- decreased thyroid function (hypothyroidism),
- poorly cured diabetes mellitus,
- prostate or pancreatic cancer.
Reasons for lowering the level of total cholesterol (hypocholesterolemia)
- Severe liver disease.
- Oncological diseases of the bone marrow.
- Increased thyroid function (hyperthyroidism).
- Intestinal malabsorption.
- Folic acid or B 12 – deficiency anemia.
- Common burns.
- Acute diseases, acute infections.
- Chronic obstructive pulmonary disease.
What can influence the result?
The cholesterol concentration may change from time to time, this is normal. A single measurement does not always reflect the usual level, therefore, it may sometimes be necessary to retake the analysis after 1-3 months.
Raise the level of total cholesterol:
- pregnancy (cholesterol test should be done at least 6 weeks after delivery),
- prolonged fasting,
- standing blood donation,
- anabolic steroids, androgens, corticosteroids,
- intake of food containing animal fats.
Reduces total cholesterol:
- blood donation while lying down,
- allopurinol, clofibrate, colchicine, antifungal drugs, statins, cholestyramine, erythromycin, estrogens,
- intense physical activity,
- diet high in polyunsaturated fatty acids.
Download an example of the result
- A cholesterol test must be taken when the person is relatively healthy.After an acute illness, heart attack, surgery, wait at least 6 weeks before measuring cholesterol.
- In the United States, cholesterol is measured in milligrams per deciliter, in Russia and in Europe – in millimoles per liter. The recalculation is carried out according to the formula: XC (mg / dL) = XC (mmol / L) × 88.5 or XC (mmol / L) = XC (mg / dL) x 0.0113.
Who orders the study?
General practitioner, therapist, cardiologist.
90,000 LDL-C Target Levels | noatero.ru
Every year 500,000 people die from coronary artery disease in Russia. In an analysis of 656,000 deaths in the United States in 2002, coronary heart disease was found to be the leading cause . The cost of treating patients with coronary artery disease in this country in 2005 amounted to 142.1 billion dollars . However, despite the proven clinical and epidemiological evidence of a link between elevated blood cholesterol levels and atherosclerosis [2-6], less than 50% of Americans who are indicated for lipid-lowering therapy receive it [7,8], while only 1/3 of patients achieve target levels of LDL cholesterol .
Approaches to the correction of hyperlipidemia continue to improve. As part of the National Cholesterol Education Program (NCEP), a panel of experts makes recommendations for the assessment and treatment of hyperlipidemia in adults. The last revision of the recommendations  with the participation of the National Heart, Lung and Blood Institute, the American College of Cardiology and the American Heart Association took place in July 2004. The results of 5 large-scale clinical trials that took place at that time [10-14] necessitated the creation of new recommendations for optimization treatment of ischemic heart disease, in which a tendency towards more aggressive management of patients with hyperlipidemia, especially those belonging to the high-risk group, has become apparent.
Optimal LDL Cholesterol Level The latest recommendations from the National Cholesterol Education Program are currently the most aggressive approach to reducing the risk of coronary artery disease. The main emphasis is on reducing LDL cholesterol levels in high-risk patients; in these patients, AHA cardiologists recommend lowering LDL cholesterol levels below 1.8 mmol / L, based on data from clinical studies. The therapeutic effect (in high-risk patients) persists even if the initial LDL-C level is <2.6 mmol / l. Although the recommended target LDL-C level remains <2.6 mmol / L, with certain co-factors, an LDL-C level of <1.8 mmol / L is desirable (Fig. 9).
Figure 9. Target LDL-C levels
Difficulties in selecting lipid-lowering therapy
The American National Cholesterol Education Program recommends the most aggressive treatment available today to reduce the risk of coronary artery disease. This approach may cause some criticism.First, there is no certainty that the number of patients benefitting from statin therapy will increase as a result of more aggressive recommendations . Second, the majority of patients already on statins will require higher doses of the drug to achieve the accepted target values. This will significantly increase the cost of lipid-lowering therapy. Considering the target LDL-C level given in the latest recommendations, less than 40% of patients treated today receive sufficient therapy to reduce the risk of coronary artery disease .And if so, the emphasis should be placed not just on the use of statins, but on their prescription in a sufficient dose to achieve the maximum possible positive effect and reduce the risk of coronary heart disease. In addition, the initial doses of statins must be appropriate to achieve the intended target LDL-C levels , otherwise the effectiveness will decrease and the cost of treatment will increase.
Patients with hyperlipidemia themselves may also face a number of difficulties. The use of stronger drugs or combination therapy can increase the cost of treatment and the incidence of side effects.This raises controversy over the appropriateness of this approach and may affect patient compliance with physician recommendations. Therefore, the indications for therapy must be carefully considered and correspond to the clinical situation and the economic possibilities of the patients.
The costs of statin therapy represent a significant part of the costs of the health care system [17, 18]. Due to the already huge medical costs in society, the increase in the cost of drugs may be the main reason for the abandonment or reduction of statins. An effective way to reduce the cost of statin therapy is to use a more effective drug. A comparative analysis of the costs of achieving the target level of LDL cholesterol with the use of various statins was carried out within the framework of the National Cholesterol Education Program (NCEP ATP II)  under the leadership of Smith and McBurney . 3887 patients were randomized to one of the following drugs: atorvastatin, fluvastatin, lovastatin, pravastatin, and simvastatin.Treatment was started with minimal doses, which were then gradually titrated to achieve target LDL cholesterol levels. The cost assessment took into account the prospects of the treatment and all costs associated with achieving the target LDL cholesterol levels. The results of the study showed that atorvastatin was associated with the lowest cost in achieving the recommended target LDL-C levels. The appearance on the domestic pharmacological market of the drug rosuvastatin has made adjustments to the pharmacoeconomic assessment of the hypolipidemic effect of statins .
In 2004, the pharmacoeconomic aspects of the use of rosuvastatin were analyzed. The cost-effectiveness of the use of rosuvastatin was studied in comparison with other drugs in this group . Pharmacoeconomic modeling was carried out based on the results of STELLAR, MERCURY I, HeFT studies. Only the costs of lipid-lowering drugs were taken into account. It was found that rosuvastatin has a higher clinical efficacy per mg and its use is most optimal in terms of cost effectiveness compared to other original statins.If the use of other statins fails to achieve the target LDL-C level, then it is economically feasible to use rosuvastatin. This trend is observed in all patient subpopulations, but is most pronounced in the high-risk subpopulation. This analysis allows rosuvastatin to be recommended in different patient subpopulations, since it has advantages over other drugs in terms of pharmacoeffectiveness .
Similar results were obtained in the American pharmacoeconomic study based on the results of STELLAR. A comparison was made between the pharmacoeffectiveness of rosuvastatin and other statins – atorvastatin, pravastatin and simvastatin. The controlled parameter was the LDL cholesterol level. The reduction in treatment costs was taken into account. The best pharmacoeconomic efficacy was found for rosuvastatin. It was noted that patients who were prescribed rosuvastatin had the highest “willingness to pay for treatment”, since the target LDL cholesterol levels were achieved at the starting dose in most cases .
The choice between statin monotherapy or combination therapy should be evaluated on a case-by-case basis.In our opinion, statin monotherapy should be preferred. The correctness of this approach has been confirmed by the results of studies on the primary and secondary prevention of cardiovascular diseases. It should be noted that “strong” statins provide a sufficient reduction in LDL cholesterol levels in most patients . In addition, when administered at optimal doses, statins are associated with lower economic costs, fewer doctor visits, and an overall reduction in treatment costs. It is clear that the cost of lipid-lowering therapy may increase as a result of the latest more aggressive guidelines (NCEP).Nevertheless, statin therapy has proven to be cost effective in primary and secondary prevention of coronary artery disease [24, 25].
The National Cholesterol Education Program has issued guidelines for correcting hyperlipidemia based on the results of recently completed well-designed controlled clinical trials. The report includes several new provisions reflecting the further development of the understanding of the relationship between dyslipidemia and coronary heart disease, which, we hope, will allow more effective treatment of patients, thereby reducing the risk of cardiovascular events.Following the recommendations will significantly reduce the morbidity and mortality associated with elevated blood cholesterol levels.
- American Heart Association. Heart Disease and Stroke Statistics 2005 Update. Dallas, Texas. American Heart Association, 2005.
- Castelli WP, Garrison RJ, Wilson PW, et al. Incidence of coronary heart disease and lipoprotein cholesterol levels. The Framingham Study. JAMA 1986; 256 (20): 2835-38.
- Stamler J, Daviglus ML, Garside DB, et al.Relationship of base line serum cholesterol levels in 3 large cohorts of younger men to long-term coronary, cardiovascular, and all-cause mortality and to longevity. JAMA 2000; 284 (3): 311-18.
- Stamler J, Wentworth D, Neaton JD. Is relationship between serum cholesterol and risk of premature death from coronary heart disease continuous and graded? Findings in 356,222 primary screenees of the Multiple Risk Factor Intervention Trial (MRFIT). JAMA 1986; 256 (20): 2823-28.
- Anderson KM, Castelli WP, Levy D.Cholesterol and mortality. 30 years of follow-up from the Framingham study. JAMA 1987; 257 (16): 2176-80.
- Levine GN, Keaney JF Jr, Vita JA. Cholesterol reduction in cardiovascular disease. Clinical benefits and possible mechanisms. N Engl J Med 1995; 332 (8): 512-21.
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