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Dyslipidaemia and statin therapy
The LDL target is set by cardiovascular risk — the higher the risk, the lower the target — and treatment escalates in steps: a high-intensity statin, then ezetimibe, then a PCSK9 inhibitor.
Why it matters in the exam
Questions test the target table (below 55 mg/dL at very high risk, below 70 at high risk, below 100 at moderate risk), the order of adding drugs, and statin side effects: muscle pain, raised liver enzymes and, rarely, rhabdomyolysis, especially combined with gemfibrozil, macrolides, azoles or cyclosporine. Candidates are also asked what monitoring is needed: ALT before treatment and once after 8–12 weeks, and CK only when there are symptoms.
Other subjects: familial hypercholesterolaemia (LDL above 190 mg/dL, tendon xanthomas, early cardiac events in the family), which calls for cascade screening of relatives; severe hypertriglyceridaemia (above 1,000 mg/dL), which risks pancreatitis and is treated with a fibrate; measuring Lp(a) once in a lifetime; and secondary causes to exclude before treatment — hypothyroidism, nephrotic syndrome, cholestasis and drugs. Statins are forbidden in pregnancy.
Key points
- LDL targets: below 55 at very high risk, below 70 at high risk, below 100 at moderate risk (mg/dL).
- Steps: high-intensity statin, ezetimibe, then a PCSK9 inhibitor.
- Monitoring: ALT before and after 8–12 weeks; CK only with symptoms.
- Familial hypercholesterolaemia: LDL above 190, xanthomas, family screening.
- Triglycerides above 1,000 mg/dL: risk of pancreatitis — fibrate.
Summary table
| Risk category | Examples | LDL target | Note |
|---|---|---|---|
| Very high risk | Documented cardiovascular disease, diabetes with target-organ damage, severe CKD (eGFR below 30) | Below 55 mg/dL and at least a 50% reduction | Recurrent event within 2 years — consider below 40 |
| High risk | Familial hypercholesterolaemia, moderate CKD, a single markedly elevated risk factor | Below 70 mg/dL and at least a 50% reduction | — |
| Moderate risk | Young patients with short-duration diabetes, moderate risk score | Below 100 mg/dL | — |
| Treatment steps | High-intensity statin (atorvastatin 40–80 mg, rosuvastatin 20–40 mg) | If not at target: ezetimibe; then a PCSK9 inhibitor | Statin intolerance: bempedoic acid or ezetimibe |
| Triglycerides | Above 1,000 mg/dL — risk of pancreatitis | Fibrate, stop alcohol, control glucose | Gemfibrozil with a statin raises the risk of rhabdomyolysis |
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Sources
- ESC/EAS Guidelines for the management of dyslipidaemias, 2019 — Risk categories, LDL-cholesterol targets and treatment steps
- ESC Guidelines on cardiovascular disease prevention in clinical practice, 2021 — Lipids
- Harrison's Principles of Internal Medicine, 21st edition (2022) — Lipoprotein Disorders
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.