1. Why Is LDL-C (the “Bad” Cholesterol) So Important?
Low-density lipoprotein cholesterol (LDL-C) is what we commonly call the “bad” cholesterol. It deposits in the artery walls and gradually forms atherosclerotic plaques, making it the principal driver of myocardial infarction, stroke, and peripheral artery disease.

Your LDL-C target is not the same as everyone else’s; it must be set according to your overall cardiovascular risk. Risk is divided into five levels, from low to extremely high:

The “cardiovascular risk factors” referred to in the table are the following six:

• Hypertension
• Age (men ≥ 45; women ≥ 55 years)
• Family history of premature coronary disease (first-degree male relative ≤ 55, or first-degree female relative ≤ 65 years at onset)
• Low HDL-C (men < 40; women < 50 mg/dL)
• Cigarette smoking
• Metabolic syndrome (meeting at least three of: abdominal obesity, elevated blood pressure, elevated fasting glucose, elevated triglycerides, low HDL-C)

Statins are the most effective and best-studied medications for lowering cholesterol. Most patients begin with a moderate- to high-intensity statin. If LDL-C remains above goal after 6–8 weeks, the next steps, in order, are:

• Review medication adherence (the most commonly overlooked issue).
• Increase the statin dose, or switch to a higher-intensity statin.
• Add Ezetimibe.
• Add PCSK9 inhibitors or an ATP citrate lyase inhibitor — reserved for very-high or extremely-high-risk patients, or for those who cannot tolerate statins.

At the same time, please make sure your other cardiovascular risks are also well controlled: blood pressure < 130/80 mmHg, HbA1c < 7%, smoking cessation, weight control, and regular exercise.

• Diet: more vegetables, fruit, whole grains, legumes, nuts, and fish; less red meat, processed meat, deep-fried foods, and sugar-sweetened beverages; avoid trans fats (commonly found in pastries, non-dairy creamer, and fast-food fryers).
• Exercise: at least 150 minutes per week of moderate-intensity aerobic exercise (such as brisk walking, swimming, or cycling), plus strength training twice a week.
• Weight: if overweight or obese, aim first for 5% weight loss; triglycerides typically improve markedly with even modest weight reduction.

• Just starting therapy or after a dose change: Recheck LDL-C in 6–8 weeks to confirm the goal is met.
• High risk and above (already at goal): Recheck a complete lipid panel every 6 months.
• Low / moderate risk (already at goal): Rechecking every 6–12 months is sufficient.

If any of the following applies to you, please tell your physician so an evaluation for familial hypercholesterolemia can be arranged:

• LDL-C ≥ 190 mg/dL
• Tendon xanthomas (especially on the Achilles tendon)
• Premature cardiovascular disease in yourself or a first-degree relative (men ≤ 55, women ≤ 65 years at onset)

In these patients, LDL-C is elevated from birth, and the cumulative damage to the vessels far exceeds that of the general population. Starting treatment early, however, dramatically improves long-term outcomes. We also recommend that your siblings and children be screened.

• Get a complete lipid panel (total cholesterol, LDL-C, HDL-C, triglycerides) drawn at the hospital.
• Discuss your risk level and LDL-C target with your physician.
• Take medication consistently, modify your lifestyle, and attend follow-up visits as recommended.

Vascular health is built up over time. The earlier you act, the more decades of high quality of life you preserve for your heart and your brain.

If you have any questions about your lipid report or treatment plan, please bring them to your next visit at the Cardiology or Family Medicine clinic.