How Different Categories of High Cholesterol Are Treated

In the recent past, the chief reason healthcare providers prescribed treatment for cholesterol was “high cholesterol levels.” If your cholesterol blood test was deemed to be “too high,” your healthcare provider would likely recommend treatment—perhaps with lifestyle changes, such as diet and exercise, or perhaps with one of several kinds of medications available for reducing cholesterol levels.

Low-density lipoproteins, illustration

Several years of clinical research, however, led experts to the conclusion that this was the wrong approach. In 2013, new guidelines were published by a group of experts from the American Heart Association and the American College of Cardiology. These guidelines recommend an entirely different approach to treating cholesterol.

Today, treatment recommendations are not based solely on cholesterol levels, but rather, on the overall level of cardiovascular risk. Cholesterol levels themselves are taken into account, but only as one of the many factors that determine cardiac risk.

Who Needs to Be Treated?

To reiterate, according to the 2013 guidelines, whether you need to be treated depends on your overall level of risk for developing cardiovascular disease. While your LDL cholesterol level certainly contributes to this risk, your risk may be quite high whether the LDL level is elevated or not.

Estimating your overall risk means that your healthcare provider will need to take into account your medical history, physical exam, and yes, your lab results. Once this is done, your healthcare provider should assign you to one of five risk categories:

Category 1

You are in this category if you already are known to have atherosclerosis which has produced a clinical problem. Category 1 includes people who have had any of the following:

Category 2

Category 2 includes people who have LDL cholesterol levels greater than 189 mg/dL. Most people in Category 2 will have one of the forms of familial hypercholesterolemia. Notably, this is the only category in which treatment is recommended solely because cholesterol levels are “too high.”

Category 3

Category 3 includes people between the ages of 40 and 75 who have diabetes, and who are not in Categories 1 or 2.

Category 4

Category 4 includes people who are not in any of the first three categories, but whose cardiac risk factors place them at high risk for cardiovascular disease. Specifically, these are people whose estimated risk of having a serious cardiovascular event (such as heart attack or stroke) is at least 7.5% over the next 10 years. To help estimate your 10-year risk, the NHLBI has provided a simple online risk calculator.

Category 5

Category 5 includes everyone who does not fit into the first four categories. These people are at low cardiovascular risk and do not require treatment.

Who Needs To Be Treated?

Everyone in Categories 1 through 4 has a high risk of significant cardiovascular problems within a few years, and they need to be treated aggressively to reduce their risk.


The 2013 guidelines on cholesterol have made a marked shift in what treatment is recommended for people in the high-risk categories. Whereas older guidelines emphasized reducing cholesterol to target treatment levels, the new guidelines do not. Rather, they emphasize reducing overall cardiac risk instead of recommending target cholesterol levels. This risk reduction is based on aggressive lifestyle changes, and on the use of statin drugs.

Controversy Surrounding Category 4

People who are in Categories 1 to 3 undeniably have a very high risk of developing cardiovascular problems, and they clearly need aggressive therapy to reduce that risk. Category 4, on the other hand, was established to find those individuals who are at an elevated risk, but a risk that is somewhat lower, and somewhat less obvious, than in the first three categories. Defining who ought to be placed into Category 4, therefore, is inherently a somewhat arbitrary process and will naturally be open to criticism.

There are two general kinds of criticism being made about Category 4. The first claims that Category 4 includes too many people. These critics point out that the risk calculator provided by the NHLBI places a lot of emphasis on age. For this reason, many people over the age of 60 will find themselves at or very near the 7.5% cutoff. Furthermore, say these critics, 10-year risk of 7.5% itself is too liberal. Treatment recommendations in the past tended more toward a cutoff of 10%. Arbitrarily lowering the treatment cutoff to 7.5%, they say, adds “too many” people to the treatment list.

The second kind of criticism regarding Category 4, not surprisingly, claims that not enough people are included in the treatment list. These critics point out that the NHLBI’s risk calculator incorporates only those risk factors which have been “proven” in well-controlled clinical trials to contribute significantly to cardiovascular risk: age, LDL, and HDL cholesterol levels, whether one is currently a smoker, and whether one has had elevated systolic blood pressure. It leaves out other risk factors that are widely accepted as being important, but which do not currently fit the NHLBI’s strict standards for inclusion. Such risk factors include a family history of premature cardiovascular disease, a past history of smoking, elevated CRP levels, a sedentary lifestyle, and a positive coronary artery calcium scan. If these important risk factors were included, many more people would meet the treatment criteria.

Such a controversy—whether Category 4 includes too many or too few people—is inherent to any recommendation whose cutoff is determined arbitrarily by a panel of experts.

Whether an individual’s risk factors are sufficient to warrant treatment ought, at least partially, to be left to the individual patient and their healthcare provider. How much risk is a person willing to accept of having a heart attack or stroke during the next 10 years? 7.5%? 10% Some other value? Should the NHLBI risk calculator be accepted at face value, or should additional risk factors be taken into account in deciding on treatment?

It is certainly appropriate for an expert panel to make recommendations in this regard. But for questions like this one, that inherently ought to be determined by individuals, those recommendations should not be binding. The final decision on whether to treat should be left to individual healthcare providers and patients.

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  • Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: A report of the American College of Cardiology/American Heart Association. J Am Coll Cardiol 2013.

By Richard N. Fogoros, MD
Richard N. Fogoros, MD, is a retired professor of medicine and board-certified in internal medicine, clinical cardiology, and clinical electrophysiology.