Cholesterol Management: LDL, Statins, and Who Is Missing Out

Managing cholesterol well is a key part of preventing atherosclerotic cardiovascular disease (ASCVD). Proven treatments are easy to get, and treatment protocols and decision aids help clinical teams and patients choose well — which means fewer heart attacks and strokes.

What cholesterol does

Cholesterol is a waxy, fatlike substance, made by the liver and also found in food. It is a major part of cell membranes and is used to make hormones, vitamin D and the bile acids that help digestion.

It travels in the blood on lipoproteins:

Excess LDL is laid down in artery walls all over the body. That can lead to ASCVD — heart attack, stroke, transient ischemic attack (TIA), stable or unstable angina, and peripheral artery disease (PAD), including aortic aneurysm, when caused by atherosclerosis.

Familial hypercholesterolemia

As many as 1 in 212 U.S. adults may have familial hypercholesterolemia (FH), an inherited disorder in which the liver struggles to process and clear excess LDL, so LDL runs very high and ASCVD can come early.

• Treatment: a healthy lifestyle plus statins, started early and followed closely to reach goals.
• Experts estimate that at least 90% of people with FH have not been properly diagnosed.
• FH accounts for about 5% of heart attacks each year in Americans under 60.

Statins

Statins (HMG-CoA reductase inhibitors) lower LDL by making the liver produce less cholesterol, and help it remove LDL already in the blood.

Many who could benefit don't take them. In 2013–2014, only about half (54.5%) of U.S. adults over 21 who might benefit were on a statin:

The 39.1 million people at high risk of an ASCVD event who are not on a statin could cut their risk of heart attack or stroke by up to half if they took one regularly.

Side effects. That benefit should be weighed against a small risk of harm:

• Rarely, statins cause myopathy — muscle damage, often with enzymes released into the blood.
• About 10% to 25% of patients in everyday practice report muscle aches or weakness after starting a statin. Yet several large blinded randomized trials found no difference in muscle symptoms between people on a statin and people on a placebo.
• The gap is probably because patients and clinicians wrongly blame statins for muscle problems — perhaps the "nocebo" effect, where people get side effects because they expect them. There are practical ways to manage reported muscle symptoms.

Beyond statins

The 2018 ACC/AHA guidelines say that people at very high risk whose LDL stays too high on the maximum statin dose may also benefit from:

Those 2018 recommendations have since been replaced by a 2026 guideline on managing dyslipidemia from the same organizations and others. For clinics, Million Hearts® offers a Cholesterol Management Change Package, developed with the National Association of Community Health Centers and the American Medical Association, listing proven process improvements.

Sources

Based on "Cholesterol Management," Million Hearts®, U.S. Department of Health and Human Services, content provided and maintained by the Centers for Disease Control and Prevention; a work of the United States government in the public domain.