High cholesterol treatment aims to reduce cardiovascular risk by lowering LDL through lifestyle interventions and medications. Clinicians use the 10-year ASCVD risk plus clinical history to decide who needs drugs. Statins are first-line; ezetimibe, PCSK9 inhibitors, inclisiran, and bempedoic acid are additional options for patients who need further LDL lowering or cannot tolerate statins.

What high cholesterol treatment aims to do

High cholesterol treatment lowers elevated cholesterol to reduce risk of heart attack, stroke, and other cardiovascular problems. Treatment combines targeted lifestyle changes with medications when needed. The main focus is lowering low-density lipoprotein (LDL) - the type most strongly linked to artery plaque and cardiovascular events - while supporting overall heart-healthy habits.

How clinicians decide who needs treatment

Doctors assess overall cardiovascular risk, not just a single cholesterol number. They use the 10-year atherosclerotic cardiovascular disease (ASCVD) risk estimate plus clinical factors (history of heart attack or stroke, diabetes, blood pressure, smoking, family history) to guide treatment. For people at highest risk, clinicians aim for lower LDL levels (for example, LDL <70 mg/dL in many high-risk patients) and will add therapies if statins alone are insufficient .

First-line: lifestyle changes

Lifestyle measures remain essential and often reduce or delay the need for drugs.
  • Diet: emphasize a Mediterranean- or DASH-style eating pattern, reduce saturated and trans fats, limit processed foods, and prioritize vegetables, whole grains, legumes, nuts, fatty fish, and olive oil.
  • Exercise: aim for at least 150 minutes of moderate aerobic activity per week, plus strength training as tolerated.
  • Weight: losing excess weight lowers LDL and triglycerides and raises HDL in many people.
  • Tobacco: quitting smoking reduces cardiovascular risk quickly and substantially.
These changes help even when medications are required.

Drug therapy options

Statins remain the cornerstone of drug treatment. They reduce LDL cholesterol by blocking cholesterol synthesis in the liver and have strong evidence for lowering heart attacks and deaths.

If LDL remains high despite maximally tolerated statin therapy, clinicians can add nonstatin agents:

  • Ezetimibe: reduces intestinal cholesterol absorption and lowers LDL further when combined with a statin.
  • PCSK9 inhibitors (monoclonal antibodies) such as evolocumab or alirocumab: substantially lower LDL and reduce cardiovascular events for high-risk patients.
  • Inclisiran: an siRNA therapy given twice-yearly that reduces LDL by targeting PCSK9 production.
  • Bempedoic acid: an oral agent that lowers LDL for patients who cannot tolerate higher-dose statins.
  • Bile acid sequestrants and fibrates: still used in select cases (bile acid binders for LDL, fibrates primarily for very high triglycerides).
Niacin is no longer routinely recommended for cardiovascular risk reduction because trials did not show added benefit when combined with statins and it can cause side effects.

Key takeaways

Treating high cholesterol combines risk assessment, lifestyle change, and medications when needed. Statins are first-line; newer therapies allow large LDL reductions for people who remain at risk despite statins or who cannot tolerate them. Discuss goals and options with your clinician to choose an individualized plan.
  1. Confirm current LDL threshold targets and exact guideline recommendations (e.g., LDL <70 mg/dL for very high-risk patients) and cite the most recent ACC/AHA or other guideline year [[CHECK]]

FAQs about High Cholesterol Treatment

When should I start medication for high cholesterol?
Medication is recommended when your estimated 10-year ASCVD risk and clinical profile indicate substantial future risk, or if you already have cardiovascular disease. Many clinicians begin with lifestyle changes and start drugs if risk is high or LDL remains above guideline goals.
Are statins safe long-term?
Statins are generally safe and well-studied for long-term use and reduce heart attacks and deaths. Side effects can include muscle aches and, rarely, liver enzyme changes; doctors monitor for these and adjust therapy as needed.
What if I can’t tolerate statins?
If you cannot tolerate statins, several options exist: lower-intensity statin, alternate statin, or nonstatin therapies such as ezetimibe, bempedoic acid, or PCSK9-targeted treatments. Lifestyle measures remain important.
Will changing my diet really help?
Yes. A Mediterranean- or DASH-style diet that reduces saturated fats and emphasizes whole foods can lower LDL and improve overall cardiovascular health, especially combined with exercise and weight loss.
Do PCSK9 inhibitors really lower heart attack risk?
PCSK9 monoclonal antibodies substantially lower LDL and have been shown in trials to reduce cardiovascular events in high-risk patients. They are typically reserved for people with persistent high LDL despite other therapies or with very high baseline risk.