LDL Levels Still Unacceptably High for Many in the United States

Imagine a 62-year-old man who survived a heart attack 2 years ago. He takes his daily statin without missing a dose. He believes he is doing everything right. But the number that matters most, his “bad” cholesterol, is still above the level cardiologists now consider safe for someone with his history. He is on the medicine. And the medicine is not enough.

His situation, it turns out, is not the exception. It is the rule.

In a new analysis my colleagues and I just published in JAMA, we found that nearly four out of every five American adults who have already had a heart attack or stroke remain above the cholesterol levels recommended by the country’s leading heart organizations. Among the much larger group of adults who haven’t yet had a cardiac event but are at high risk, the picture is no better. And strikingly, three out of every four are not on any cholesterol-lowering medication.

This is the quiet shape of America’s biggest preventable killer. Cardiovascular disease takes more American lives every year than any other cause. We have decades of evidence that lowering "bad" cholesterol, or LDL, prevents heart attacks and strokes. The medications are cheap, safe, and widely available; the first generation went generic two decades ago. The guidelines lowered the targets precisely because the evidence has become inescapable that, for higher-risk patients, lower is better.

The updated guidelines are a chance to save lives at scale. Our findings suggest that, at the moment they took effect, the country was nowhere close to meeting them.

Why? The honest answer is not that patients are careless or that doctors don’t know what to do. It’s that the system of cholesterol care in this country was built around a single drug, the statin, taken at a moderate dose, often without anyone checking whether it worked.

For decades, that approach was good enough. It isn’t anymore. The new treatment goals often require higher-intensity statins, a second medication added to the first, or in some cases newer drugs like PCSK9 inhibitors, which are effective but more expensive and harder to get covered by insurance.

Each of those steps requires a clinician to notice that a patient is above goal, to have the time to discuss adding therapy, and to have a system that supports the follow-up labs, the prior authorizations, and the patient education. Most American medical practices do not have that system.

For people without known heart disease, the failure is even more basic: nobody started them on anything. They had a cholesterol number drawn, perhaps at a routine physical, and the result was filed away without the conversation that should have followed.

The fix is not glamorous, but it is concrete.

Physicians should ensure every adult knows two numbers: their LDL level and their personal goal, which depends on their overall risk. Primary care should treat cholesterol the way it treats blood pressure, a vital sign that is checked, discussed, and acted on at every visit, not a lab value that lives in a chart. Health systems should build automatic alerts that flag patients above goal and prompt clinicians to act. Insurers should stop turning the second-line medications into a paperwork ordeal for the patients who need them most.

The question every cholesterol visit should turn on is not “Are you on the medicine?” but “Is the medicine doing its job?” For far too many Americans, the answer is no. The consequences of that “no”—the next heart attack, the next stroke—are avoidable.

The new guidelines gave the country a clearer, more ambitious target than it has ever had. What our analysis shows is how much ground there is to cover to reach it. The science has done its part. 

We have the medicine, and we have the evidence. What we don’t yet have is the resolve to use them.

Off Script is a first-person blog written by leading voices in the field of cardiology. It does not reflect the editorial position of TCTMD.