Red Flags
- Familial hypercholesterolaemia features (LDL-C ≥190 mg/dL, tendon xanthomas, or premature CAD family history) — refer for genetic testing and high-intensity statin[1]
- Triglycerides ≥1000 mg/dL — risk of acute pancreatitis, urgent triglyceride-lowering therapy required[1]
- ASCVD with progression despite maximally tolerated statin — evaluate for PCSK9 inhibitor or inclisiran[1]
- Lipoprotein(a) ≥125 nmol/L (≥50 mg/dL) — independent ASCVD risk enhancer warranting intensified lifestyle and lipid-lowering therapy[1]
First-line treatment
Interventions
- Heart-healthy lifestyle from childhood[1]Mediterranean or DASH-pattern diet, ≥150 min/week moderate aerobic activity, weight reduction if BMI ≥25, smoking cessation, alcohol limitation. Earlier intervention emphasized in 2026 update
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Atorvastatin[1] | HMG-CoA reductase inhibitor (statin) | 40–80 mg PO once daily (high-intensity for ASCVD or LDL-C ≥190); 10–20 mg (moderate-intensity for primary prevention) | 10 mg once daily for ages ≥10 with familial hypercholesterolaemia | First-line for both primary and secondary prevention; LDL-C goal <55 mg/dL in very-high-risk ASCVD |
| Rosuvastatin[1] | HMG-CoA reductase inhibitor (statin) | 20–40 mg PO once daily (high-intensity); 5–10 mg (moderate-intensity) | 5 mg once daily for ages ≥10 with familial hypercholesterolaemia | Alternative statin; preferred with statin intolerance to atorvastatin or in renal impairment |
| Ezetimibe[1] | Cholesterol absorption inhibitor | 10 mg PO once daily | 10 mg once daily for ages ≥10 | Add when LDL-C goal not reached on maximally tolerated statin; provides additional ~20% LDL-C reduction |
| Evolocumab[1] | PCSK9 inhibitor (monoclonal antibody) | 140 mg SC every 2 weeks OR 420 mg SC monthly | — | For very-high-risk ASCVD or familial hypercholesterolaemia not at LDL-C goal on statin + ezetimibe |
Atorvastatin[1]
HMG-CoA reductase inhibitor (statin)
- Adult
- 40–80 mg PO once daily (high-intensity for ASCVD or LDL-C ≥190); 10–20 mg (moderate-intensity for primary prevention)
- Paediatric
- 10 mg once daily for ages ≥10 with familial hypercholesterolaemia
First-line for both primary and secondary prevention; LDL-C goal <55 mg/dL in very-high-risk ASCVD
Rosuvastatin[1]
HMG-CoA reductase inhibitor (statin)
- Adult
- 20–40 mg PO once daily (high-intensity); 5–10 mg (moderate-intensity)
- Paediatric
- 5 mg once daily for ages ≥10 with familial hypercholesterolaemia
Alternative statin; preferred with statin intolerance to atorvastatin or in renal impairment
Ezetimibe[1]
Cholesterol absorption inhibitor
- Adult
- 10 mg PO once daily
- Paediatric
- 10 mg once daily for ages ≥10
Add when LDL-C goal not reached on maximally tolerated statin; provides additional ~20% LDL-C reduction
Evolocumab[1]
PCSK9 inhibitor (monoclonal antibody)
- Adult
- 140 mg SC every 2 weeks OR 420 mg SC monthly
- Paediatric
- —
For very-high-risk ASCVD or familial hypercholesterolaemia not at LDL-C goal on statin + ezetimibe
Safety-net
- Statins are taken lifelong — stopping causes LDL-C to rebound and cardiovascular risk to climb back rapidly[1]
- Mild muscle aches are common and usually not serious; severe muscle pain, weakness, or dark urine — stop the statin and seek care[1]
- Routine liver function and CK are not required unless symptoms develop — do not let lab fears delay therapy[1]
Referral criteria
- Triglycerides ≥1000 mg/dL with abdominal painEmergency department — risk of acute pancreatitis[1]
- Suspected familial hypercholesterolaemia (LDL-C ≥190, tendon xanthomas, premature CAD family history)Lipid clinic for genetic testing and family cascade screening[1]
- Established ASCVD not at LDL-C goal <55 mg/dL on maximally tolerated statin + ezetimibeCardiology or lipid clinic for PCSK9 inhibitor or inclisiran[1]
- Lp(a) ≥125 nmol/L with personal or family history of premature ASCVDLipid clinic for risk-enhancer-aware management[1]
Clinical summary
Evaluation and management of elevated cholesterol, hypertriglyceridaemia, and elevated lipoprotein(a) for primary and secondary cardiovascular prevention.