Plain answers, with sources

Yes. High LDL causes no symptoms while it builds plaque in your arteries, and the first sign can be a heart attack or stroke.

How much it matters depends on how high your LDL-C is, how many years it stays high, and your other risks: blood pressure, smoking, diabetes, kidney disease and family history.

The good news is that lowering LDL works, and the sooner it comes down, the more you protect your arteries.

Source: 2018 AHA/ACC cholesterol guideline; European Atherosclerosis Society consensus, Eur Heart J 2017.

Genes set most of your LDL level. Food and exercise usually move it by 10 to 30%.

Your liver makes most of the cholesterol in your blood, and how well it clears LDL is largely inherited. About 1 in 250 people has familial hypercholesterolemia (FH), a genetic cause of very high LDL from birth.

Other things can raise LDL too: an underactive thyroid, some kidney and liver conditions, menopause, and some medicines. A simple blood test can check your thyroid.

Source: European Atherosclerosis Society FH consensus, Eur Heart J 2013; 2018 AHA/ACC cholesterol guideline.

Lowering LDL a lot can stop plaque growing, shrink it a little, and steady it, so it's less likely to crack and cause a heart attack.

In the GLAGOV imaging trial, people who brought LDL-C down to about 36 mg/dL saw plaque shrink in about 2 of 3 cases. The change is small, and a calmer, firmer plaque is less likely to rupture.

Source: GLAGOV trial, JAMA 2016.

Usually yes. LDL goes back up within a few weeks of stopping, and the benefit builds with every year it stays low.

That doesn't lock you into one medicine or one dose. Many people adjust over time, and if your diet, weight or other risks change a lot, your clinician may revisit the plan.

Please don't stop on your own. Talk it through first.

Source: Cholesterol Treatment Trialists' (CTT) Collaboration, Lancet 2010 and 2012.

It depends on your risk. Many guidelines aim for under 100 mg/dL for most adults, under 70 for high risk, and under 55 for people with heart disease or very high risk.

For LDL, lower is better, and there's no level found to be too low in trials. Your clinician sets your goal from your overall risk.

Source: 2018 AHA/ACC cholesterol guideline; 2019 ESC/EAS dyslipidaemia guideline.

LDL builds plaque, so treatment aims at LDL. HDL and triglycerides add context about your risk.

Higher HDL tends to go with lower risk, but medicines that raise HDL haven't prevented heart attacks, so it isn't a treatment target.

Triglycerides above 150 mg/dL often travel with insulin resistance and raise risk. Above 500, they can also inflame the pancreas.

Source: 2018 AHA/ACC cholesterol guideline; AIM-HIGH trial, NEJM 2011.

It counts how many of 100 people like you would have a heart attack or stroke in the next 10 years.

It comes from a calculator that uses your age, sex, blood pressure, cholesterol, diabetes and smoking. In the US, clinicians often call under 5% low, 5 to 7.5% borderline, 7.5 to 20% intermediate and 20% or more high.

Things the calculator misses, like a family history of early heart disease, high Lp(a) or a calcium score, can move your estimate.

Source: 2018 AHA/ACC cholesterol guideline; AHA PREVENT equations, Circulation 2024.

Usually not. A non-fasting test is fine for most people.

If your triglycerides come back above 400 mg/dL, your clinician may repeat the test after fasting.

Source: 2018 AHA/ACC cholesterol guideline; EAS/EFLM consensus, Eur Heart J 2016.

Sometimes, if your LDL is only a little high and your risk is low. Most people lower LDL by 10 to 30%, which may not reach their goal.

Try hard either way: the same changes help blood pressure, blood sugar and weight. If you start medicine, healthy habits make it work better.

Source: NCEP ATP III, Circulation 2002; 2018 AHA/ACC cholesterol guideline.

Swapping saturated fat for unsaturated fat, adding soluble fiber, and plant sterols. Together they add up.

Saturated fat (butter, fatty meat, cheese, coconut oil) swapped for olive oil, nuts and fish: about 8 to 10% lower LDL.

Soluble fiber, 5 to 10 g a day from oats, beans, lentils or psyllium: about 3 to 5%. Plant sterols, 2 g a day: about 6 to 15%. Losing about 10 pounds: about 5%.

Source: NCEP ATP III, Circulation 2002.

No. For most people, the cholesterol in food matters less than saturated fat.

About one egg a day fits most healthy eating patterns. What comes with it, like bacon, sausage or butter, usually matters more. Some people's LDL is more sensitive to dietary cholesterol, so recheck if you eat a lot.

Source: AHA science advisory on dietary cholesterol, Circulation 2020.

Red yeast rice can lower LDL, but the dose and purity vary. Over-the-counter fish oil doesn't lower LDL.

Red yeast rice contains the same chemical as the statin lovastatin, without the quality control of a medicine, so it can have the same side effects.

Fish oil lowers triglycerides but leaves LDL alone. A prescription form (icosapent ethyl) is used for some people with high triglycerides.

Source: US FDA warnings on red yeast rice; REDUCE-IT trial, NEJM 2019.

About 150 minutes a week of brisk walking or similar. It lowers heart risk more than it lowers LDL.

Exercise usually moves LDL only a few percent, but it lowers blood pressure, blood sugar and triglycerides, and fitness itself protects the heart. Any amount is better than none.

Source: 2019 ACC/AHA primary prevention guideline.

No one has to. Statins are usually offered first because they're cheap and have the strongest proof of preventing heart attacks and strokes.

Whether one makes sense for you depends on your LDL and your overall risk. If the choice isn't clear, a coronary calcium scan or Lp(a) test can help, and other medicines can step in if statins don't suit you.

Source: 2018 AHA/ACC cholesterol guideline; CTT Collaboration, Lancet 2010.

A moderate dose lowers LDL by 30 to 49%, a high dose by 50% or more. Each 39 mg/dL drop cuts heart attacks and strokes by about 22%.

So the higher your LDL and your risk, the more you gain. Someone at 20% risk gains much more than someone at 5%, from the same pill.

Source: CTT Collaboration, Lancet 2010; 2018 AHA/ACC cholesterol guideline.

Whenever you'll remember. Atorvastatin and rosuvastatin work the same any time of day.

Simvastatin, pravastatin and lovastatin are short-acting, so they're usually taken in the evening.

Source: US prescribing information for each statin.

Moderate alcohol is usually fine. Grapefruit matters only for some statins, and mostly in large amounts.

Large amounts of grapefruit juice raise levels of simvastatin and lovastatin, and to a lesser degree atorvastatin. Rosuvastatin and pravastatin aren't affected. Heavy drinking is hard on the liver with or without a statin.

Source: US prescribing information for each statin.

Talk to your clinician before giving up. Most people who get aches can take a different statin, a lower dose, or a non-statin medicine.

In blinded trials, 27.1% of people on a statin reported muscle aches, and so did 26.6% on a sugar pill. So most aches on a statin aren't caused by it, though some are.

Options include switching statins, a lower dose, taking it a few days a week, adding ezetimibe, or moving to bempedoic acid or a PCSK9 medicine.

Source: CTT Collaboration, Lancet 2022; SAMSON trial, NEJM 2020.

They can raise blood sugar slightly, mostly in people already close to diabetes. For people who need a statin, the heart benefit is larger.

In blinded trials, high doses raised the chance of a diabetes diagnosis more than low and moderate doses. Most of the extra diagnoses were in people whose blood sugar was already near the line.

Source: CTT Collaboration, Lancet Diabetes Endocrinol 2024.

Serious liver injury is rare, and good studies haven't shown statins harm memory.

Mild rises in liver enzymes can happen and usually settle. Routine liver tests are no longer needed unless your clinician has a reason. If you notice anything new, report it rather than stopping on your own.

Source: US FDA drug safety communication, 2012; 2018 AHA/ACC cholesterol guideline.

Yes: ezetimibe, bempedoic acid, and since 2026 Lipfendra (enlicitide), the first PCSK9 inhibitor taken as a daily pill.

Ezetimibe lowers LDL by about 20 to 25% on top of a statin and costs a few dollars a month. Bempedoic acid lowers it by about 17 to 23% and rarely causes muscle aches. Lipfendra lowers it much more and costs more.

Source: IMPROVE-IT, NEJM 2015; CLEAR Outcomes, NEJM 2023; US prescribing information.

Shots that lower LDL by about 50 to 60% on top of a statin. They're usually for very high risk, familial hypercholesterolemia, or when statins don't suit you.

Repatha and Praluent are shots every 2 or 4 weeks, Lerochol once a month, and Leqvio (a related medicine) twice a year at a clinic. Repatha and Praluent have trials showing fewer heart attacks and strokes.

Source: FOURIER, NEJM 2017; ODYSSEY OUTCOMES, NEJM 2018; ORION-10/11, NEJM 2020.

Both work. A moderate statin plus ezetimibe lowers LDL about as much as a high dose, often with fewer side effects.

Which is better for you depends on how much lower you need to go and how you feel on each.

Source: RACING trial, Lancet 2022.

Generic statins and ezetimibe: often $5 to $15 a month. Newer medicines: about $199 to $356 a month cash.

As of October 2026: Repatha and Praluent about $239 a month cash, Lerochol $199 a month through its direct program, and the Lipfendra pill about $315 to $356 a month at retail pharmacies. Leqvio mostly goes through insurance.

Source: Manufacturer and pharmacy cash prices, checked monthly by lipid.site.

Denials are common and often reversed. Ask your clinician's office to appeal with your LDL history and what you've already tried.

Insurers usually want proof that a statin (and often ezetimibe) was tried or isn't tolerated. While you wait, a manufacturer cash program can bridge the gap.

Source: lipid.site Paying for it exhibit.

ApoB counts the particles that carry cholesterol into artery walls. Lp(a) is a particle level set mostly by your genes. Both can reveal risk a normal LDL hides.

Checking Lp(a) once in adulthood is widely recommended. ApoB is most useful when triglycerides are high or LDL and your risk don't match.

Source: 2019 ESC/EAS dyslipidaemia guideline; National Lipid Association statement on Lp(a), 2024.

A quick, low-dose CT scan that looks for calcified plaque in your heart arteries. It can tip a borderline decision either way.

A score of 0 means lower near-term risk, and some people can hold off on a statin (not if you smoke, have diabetes or a strong family history). A score of 100 or more favors treatment. Insurance often doesn't cover it, but the cash price is usually modest.

Source: 2018 AHA/ACC cholesterol guideline.

If your LDL is 190 or higher, or heart disease came early in your family, yes: parents, brothers, sisters and children.

Familial hypercholesterolemia is passed down, and each child of a parent with it has a 1 in 2 chance. Children with FH can be checked from about age 2. If your Lp(a) is high, relatives should check theirs once too.

Source: European Atherosclerosis Society FH consensus, Eur Heart J 2013; 2018 AHA/ACC cholesterol guideline.