LDL Cholesterol: The Primary Driver of Atherosclerosis
LDL-C is the main carrier of cholesterol in blood and the primary causal factor in atherosclerosis. Understanding optimal levels, particle size, and how to lower cardiovascular risk.
Reference: 70-100 mg/dL (optimal), <100 mg/dL (near optimal), 100-129 mg/dL (borderline), 130-159 mg/dL (high), 160+ mg/dL (very high) mg/dL
Key Takeaway
LDL cholesterol is the primary causal factor in atherosclerosisGrundy SM, et al. 2018. Unlike total cholesterol, which includes both "bad" LDL and "good" HDL, LDL-C specifically predicts plaque buildup in arteries. The lower your LDL-C, the lower your cardiovascular risk—with no apparent lower threshold according to major clinical trialsCTT Collaboration, 2015.
What is LDL Cholesterol?
Low-density lipoprotein cholesterol (LDL-C) transports cholesterol from the liver to peripheral tissuesGrundy SM, et al. 2018. When too much LDL circulates in the blood, it can deposit in artery walls, forming plaques that narrow and harden arteries—this process is called atherosclerosis.
Think of LDL as delivery trucks dropping off cholesterol packages throughout your body. When there are more deliveries than your tissues can use, the excess gets "parked" in your artery walls, creating traffic jams that become dangerous blockages over time.
Why LDL Matters More Than Total Cholesterol
- Total cholesterol includes LDL, HDL, and VLDL—masking important individual patterns
- LDL-C is the primary target for cardiovascular risk reductionGrundy SM, et al. 2018
- HDL-C is protective and shouldn't be grouped with risk markers
- Research shows lowering LDL-C consistently reduces cardiovascular eventsCTT Collaboration, 2015
- Optimal (＜ 70 mg/dL): Ideal for high-risk patients, associated with lowest event ratesGrundy SM, et al. 2018
- Near Optimal (70-99 mg/dL): Good for most adults
- Borderline High (100-129 mg/dL): Consider lifestyle changes
- High (130-159 mg/dL): Lifestyle changes ± medication depending on riskAHA, 2023
- Very High (160+ mg/dL): Usually requires intervention
The "Lower is Better" Paradigm
Large outcome trials (CTT Collaboration) show that for every 39 mg/dL (1 mmol/L) reduction in LDL-CCTT Collaboration, 2015:
- Major vascular events decrease by ~22%
- This benefit is consistent regardless of baseline LDL
- No threshold below which further lowering doesn't help
Genetic LDL Disorders
Familial hypercholesterolemia (FH) affects 1 in 250 people. These individuals have very high LDL from birth (often 190-400+ mg/dL) and develop premature heart disease without treatmentNordestgaard BG, et al. 2016. If your LDL is very high despite healthy lifestyle, genetic testing and aggressive treatment may be needed.
Related Testing
- ApoB: Measures atherogenic particle number—superior to LDL-C
- Lp(a): Genetic risk factor independent of LDL-C
- hs-CRP: Inflammatory marker that modifies risk
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