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Your cholesterol is high. Now what?

Plaque builds while you feel fine. Lower your LDL-C now to slow it.

How would you like to start?

SHOTSPILLSRepatha /PraluentLerocholInclisiranLipfendraBempedoicacidEzetimibeStatin

Which medicine fits what matters to you? Pick any.

Watch the needle swing to the best fit. It mirrors your choices; talk the result over with your clinician.

5 scenes · about 2 minutes

What your LDL-C is doing right now

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Scene 1 of 5

1 · Today

LDL particles slip into your artery wall, and many stay.

Each particle carries one apoB protein, so apoB counts the particles. The more particles in your blood, the more get stuck.

People born with genes that keep LDL-C about 39 mg/dL lower all their lives have about half the risk of heart disease. Source: Ference et al., J Am Coll Cardiol 2012

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  1. 1 · Today. LDL particles slip into your artery wall, and many stay. Each particle carries one apoB protein, so apoB counts the particles. The more particles in your blood, the more get stuck. People born with genes that keep LDL-C about 39 mg/dL lower all their lives have about half the risk of heart disease. Source: Ference et al., J Am Coll Cardiol 2012.
  2. 2 · The years. Year after year, the stuck cholesterol builds into plaque. You feel fine. Cleanup cells swallow the stuck cholesterol and swell into foam cells. Together they build a fatty plaque inside the wall. Plaque can start in your twenties. In 4,184 healthy adults aged 40 to 54, scans found plaque in 63%. Source: PDAY study, Am J Clin Nutr 2000; PESA study, Circulation 2015.
  3. 3 · Decades. The plaque keeps growing and narrows the artery. A cap of scar tissue covers a soft, fatty core. Less room remains for blood on its way to your heart muscle. Doctors usually count a heart artery as seriously narrowed at 70% or more. That much can limit blood flow when you exert yourself. Source: AHA/ACC chest pain guideline, Circulation 2021.
  4. 4 · One day. A plaque cracks, and a blood clot forms on it. Platelets rush to the tear and pile up. Plaques with a thin cap crack most easily, even small ones. About 2 in 3 heart attacks start at a plaque that narrowed the artery by less than half. Source: Falk, Shah and Fuster, Circulation 1995 (pooled angiography studies).
  5. 5 · Heart attack. The clot blocks the artery. The heart muscle beyond it starts to die. No blood gets past, so that part of the heart gets no oxygen. That's a heart attack. Many strokes start the same way, in an artery to the brain. Someone in the US has a heart attack every 40 seconds. About 1 in 5 heart attacks is silent: the damage happens, and the person doesn't notice. Source: CDC, Heart Disease Facts.

Lowering LDL-C slows every step you just saw.

Here's how, in order: your own numbers, then food and exercise, then medicines one step at a time.

Start with my numbers ↓Skip to the medicine steps ↓
1

Your numbers

Lower your LDL, lower your risk.

Of 100 people like you, about 10 have a heart attack or stroke in the next 10 years.

For an LDL-C of 160 and middle risk ·

Trial averages. Your own result can differ. See the details

Next: why it matters
2

Why it matters

The longer LDL stays high, the more plaque builds

LDL exposure, running total020406080AgeHeart trouble can start around hereYou, 45age 46age 48

Stay at 160 Lower to 70 now Your years so far LDL-C of 100 all along

At 160, you'd reach that level around age 46. Lowering to 70 now pushes that to about 48.

From today on, your total would build up 56% slower.

Using an example LDL-C of 160. The running total is LDL-C times years. It assumes LDL-C of about 100 as a child, then today's level from age 20 on. The band is about 6,200 mg/dL-years (160 mmol/L-years), where heart disease tends to appear (European Atherosclerosis Society, Nordestgaard et al., Eur Heart J 2013). An illustration of the idea. Your own arteries can differ.

Next: more tests How worried should I be?
3

Want more data first?

More tests can help you decide

ApoB

Counts the particles. Two people with the same LDL-C can carry it in very different numbers of particles.

apoB: 6 particlesapoB: 14 particles

Lp(a)

An extra-sticky particle set by your genes. Test it once.

125 nmol/L (50 mg/dL)

About 1 in 5 people are above this line. Genes set most of it, so one test in adulthood is usually enough.

Calcium (CAC) scan

Shows calcium in plaque that has already formed. It can move your risk estimate up or down.

What the scan sees
Your artery
Artery wallBlood channelSoft plaqueCalcium

What's really in the wall: soft plaque, with calcium in some of it.

Calcium scan (no dye)
LADRCALCxHeartLungRLSlicesThis sliceExample score: 42

Only calcium shows. Soft plaque is invisible, so a score of 0 lowers risk but doesn't rule out plaque.

Some calcified plaque. Plaque is present, which often tips the balance toward treatment to lower LDL.

Next: what to eat Tests to ask for What do my numbers mean?
4

Food first

What to eat, starting this week

How closely?
100
70
55

Now

With these changes

Pick a change to see what it does.

A day of eating

What this looks like on a plate

  1. BreakfastOatmeal with a spoon of psyllium and berriesSoluble fiber
  2. LunchBean and barley salad with olive oilSoluble fiber, better fat
  3. SnackA handful of walnuts or almondsBetter fat
  4. DinnerFish or tofu, vegetables cooked in olive oilBetter fat
  5. Any timeA drink, yogurt or spread with added plant sterols (2 g)Plant sterols

This day delivers about 8 g of soluble fiber and 2 g of plant sterols, and swaps butter and pastries for olive oil and nuts.

Next: medicines, step by step Walk through the Kitchen Why is mine high if I eat well?
5

Medicines, step by step

If LDL-C stays high, medicines add up one step at a time

Example

An LDL-C of 160 mg/dL, step by step

Statin dose:
  1. Todayno medicine160
  2. Step 1high-intensity statin80
  3. Step 2+ ezetimibe61
  4. Step 3+ PCSK9 inhibitor27
Dashed lines: common LDL-C goals (under 100, 70 or 55 mg/dL, depending on risk). Average trial effects, each step on top of the one before. An example only: your own result can differ, and a clinician sets your goal.

  1. Step 1

    High-intensity statin

    atorvastatin, rosuvastatin and others, generic · Pill, daily

    Lowers LDL-C
    50% or more
    Example after this step
    about 80 mg/dL (50% lower in total)
    Proven to cut heart attacks and strokes
    • In trials of about 170,000 people, each 39 mg/dL drop in LDL-C meant about 22% fewer heart attacks, strokes and artery-opening procedures.
    • Each 39 mg/dL drop also meant about 10% fewer deaths from any cause.

    Source: Cholesterol Treatment Trialists' (CTT) Collaboration, Lancet 2010

  2. Step 2

    Add ezetimibe

    Zetia, generic · Pill, daily

    Lowers LDL-C
    about 20 to 25% more
    Example after this step
    about 61 mg/dL (62% lower in total)
    Proven to cut heart attacks and strokes
    • IMPROVE-IT: 18,144 people after a heart attack or unstable angina, all on a statin. Adding ezetimibe took LDL-C from about 70 to 54 mg/dL.
    • Over 7 years, 32.7% had a major heart or stroke event, against 34.7% on the statin alone. Heart attacks fell 13% and strokes from a blocked artery 21%. Deaths didn't differ.

    Source: Cannon et al., IMPROVE-IT, NEJM 2015

  3. Step 3

    Add a PCSK9 inhibitor shot

    evolocumab, alirocumab (Repatha, Praluent) · Shot every 2 or 4 weeks

    Lowers LDL-C
    about 50 to 60% more
    Example after this step
    about 27 mg/dL (83% lower in total)
    Proven to cut heart attacks and strokes
    • FOURIER: 27,564 people with heart or artery disease on a statin. Evolocumab took LDL-C from 92 to 30 mg/dL. Over about 2 years: 15% fewer major events, 27% fewer heart attacks, 21% fewer strokes. Deaths didn't differ in that time.
    • ODYSSEY OUTCOMES: 18,924 people after a heart attack or unstable angina. Alirocumab cut major events by 15%. Deaths from any cause: 3.5% against 4.1%. The trial reported that difference as nominal, because of the order its statistics were planned in.
    • GLAGOV imaging trial: in people who reached an LDL-C near 36 mg/dL, plaque shrank in about 2 of 3.

    Source: Sabatine et al., FOURIER, NEJM 2017; Schwartz et al., ODYSSEY OUTCOMES, NEJM 2018; Nicholls et al., GLAGOV, JAMA 2016

Other options that fit on the ladder

Some people can't take a step, or would rather take it another way. These can stand in.

  • Bempedoic acid (Nexletol)

    Can't take a statin? It can stand in at step 1, or add on.

    Pill, daily

    Lowers LDL-C about 17 to 23%

    Proven to cut heart attacks and strokes

    CLEAR Outcomes: 13,970 people who couldn't take a statin. 13% fewer major heart and stroke events, 23% fewer heart attacks. Deaths didn't differ.

    Source: Nissen et al., CLEAR Outcomes, NEJM 2023

  • Inclisiran (Leqvio)

    Another way to lower PCSK9 at step 3, with fewer shots.

    Shot at a clinic: day 0, month 3, then every 6 months

    Lowers LDL-C about 50%

    Outcome results not yet in

    Outcome trials (ORION-4, VICTORION-2 PREVENT) hadn't reported as of October 2026.

    Source: Ray et al., ORION-10 and ORION-11, NEJM 2020

  • Lerochol (lerodalcibep)

    A monthly PCSK9 shot at step 3.

    Shot once a month

    Lowers LDL-C about 56% more than placebo at one year

    Outcome results not yet in

    Newer, with less long-term outcome data so far.

    Source: LIBerate-HR trial, presented ACC 2024

  • Lipfendra (enlicitide)

    A daily PCSK9 pill at step 3.

    Pill, daily, fasting

    Lowers LDL-C about 56 to 59% more than placebo

    Outcome results not yet in

    Approved July 2026. Its outcome trial is still running.

    Source: CORALreef Lipids and CORALreef HeFH trials

Watch how each medicine works, with prices
Next: are they safe? Compare them all in the Medicine Hall
6

Safety

Cholesterol medicines work, and monitoring keeps them safe

Took a statin100 people
Took a sugar pill100 people

What monitoring looks like: a lipid panel about 4 to 12 weeks after starting or changing a dose, then every 3 to 12 months. Liver enzymes only if your clinician thinks they're needed.

Next: take it to your visit Visit the Myth Lab

lipid.site · Your take-home cardSample

LDL-C
160 mg/dL
10-year risk
about 10%

Options I tried on

  • Pick a scenario above

Questions for my clinician

  • What LDL-C goal is right for me, and why?
  • Should we check my apoB and Lp(a)?

Yours fills in as you go.

Take it to your next visit

The full card adds what you learned, what matters to you, and questions picked for your numbers. Print it. Your browser makes it, with no name on it.

Take the full guided tour (about 15 minutes)See my card

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