How plaque builds
Cholesterol travels through your blood inside particles called lipoproteins. The ones that cause trouble, mainly LDL, can slip into the artery wall, get stuck, and trigger inflammation. Over decades, this builds into plaque. Plaque can narrow an artery, or rupture and trigger the clot behind most heart attacks and many strokes.
Two things drive how much plaque you build: how many of these particles are in your blood, and for how long. That's why lowering LDL earlier in life has an outsized payoff, and why "slightly high for 30 years" matters.
Reading your lipid panel
| Measure | What it means | General target |
|---|---|---|
| LDL-C ("bad") | The cholesterol carried in LDL particles, and the main treatment target. | Under 100 mg/dL for most people. Lower if you have heart disease, diabetes, or high risk. |
| HDL-C ("good") | Associated with lower risk, but raising it with drugs hasn't been shown to help. | 40+ mg/dL for men |
| Triglycerides | Blood fats, driven by alcohol, sugar, refined carbs, and insulin resistance. | Under 150 mg/dL |
| Non-HDL-C | Total cholesterol minus HDL. It captures all the harmful particles, and it's useful when triglycerides are high. | Under 130 mg/dL |
| Total cholesterol | On its own, not very informative. | — |
An LDL of 190 mg/dL or higher points to a possible inherited condition, familial hypercholesterolemia. Guidelines generally recommend treatment at that level, and your close relatives should be tested too.
ApoB: a better measure
Every potentially plaque-causing particle (LDL, VLDL, and Lp(a)) carries exactly one apolipoprotein B (ApoB) molecule. So an ApoB test counts the particles directly, instead of estimating how much cholesterol they carry.
Most of the time, ApoB and LDL-C tell the same story. But they can disagree, especially in men with high triglycerides, insulin resistance, or diabetes. In those cases LDL-C can look fine while the particle count, and the risk, is high. Many lipid specialists now consider ApoB the better target, and European guidelines endorse it.
It's an inexpensive blood test. Ask for it, especially if you have metabolic syndrome, prediabetes, or a family history of early heart disease.
Lp(a): the genetic wildcard
Lipoprotein(a) is an LDL-like particle whose level is almost entirely set by your genes. Diet and exercise barely move it. Roughly 1 in 5 people have an elevated level (commonly defined as over about 50 mg/dL, or about 125 nmol/L), which meaningfully raises the risk of heart attack, stroke, and aortic valve disease.
Because it barely changes, several expert groups recommend testing it once in your life. It's especially worth checking if you or a close relative had a heart attack or stroke at a young age. There isn't yet an approved drug that specifically lowers Lp(a), though several are in late-stage trials. Knowing you're high still matters, because it's a reason to control LDL, blood pressure, and everything else more aggressively.
Estimating your risk
Doctors decide whether to treat cholesterol based on your overall risk, not just LDL. In the U.S., the American Heart Association's PREVENT calculator estimates your 10- and 30-year risk of heart disease using age, cholesterol, blood pressure, diabetes, smoking, and kidney function. It replaces the older "pooled cohort equations."
Things that aren't in the calculator but can push risk higher, and treatment decisions toward starting sooner:
A 10-year risk sounds reassuring for a 40-year-old almost no matter what. Asking about your 30-year or lifetime risk gives a truer picture when you're younger.
Coronary calcium scans
A coronary artery calcium (CAC) scan is a quick, low-dose CT scan that detects calcified plaque in the heart's arteries. It's usually self-pay and relatively inexpensive, often around $100–$200.
| CAC score | What it generally means |
|---|---|
| 0 | No calcified plaque. Very low near-term risk, and some people at borderline risk can reasonably hold off on a statin (unless they smoke, have diabetes, or have a strong family history). |
| 1–99 | Some plaque. Treatment is generally favored, especially after age 55. |
| 100+ | Significant plaque. Statin treatment is recommended. |
It's most useful when you're on the fence about treatment, typically in men over 40 at borderline or intermediate risk. A zero score doesn't rule out soft, uncalcified plaque, especially in younger men, and it isn't a screening test for people with symptoms like chest pain.
What diet actually does
Diet reliably lowers LDL, typically by around 10–20% with a real, sustained effort. That's less than a statin, but meaningful, and it helps blood pressure and blood sugar at the same time. What works:
- ✓Replace saturated fat (fatty red meat, butter, cheese, coconut oil) with unsaturated fat: olive oil, nuts, avocado, fish. Replacing it with refined carbs doesn't help.
- ✓More soluble fiber: oats, barley, beans, lentils, and psyllium supplements.
- ✓Cut trans fats entirely. They're now largely gone from the U.S. food supply, but check labels for partially hydrogenated oils.
- ✓For high triglycerides, cut alcohol, sugary drinks, and refined carbs, and lose weight. Triglycerides often respond quickly.
A word on very low-carb, high-fat diets: some people, often lean and active men, see large LDL and ApoB increases on keto-style diets. If you eat this way, get your lipids checked.
Supplements like red yeast rice contain a natural statin (monacolin K) in unregulated, variable doses. If you need a statin, a prescription one is more predictable and safer.
Statins
Statins (atorvastatin, rosuvastatin, and others) lower LDL by roughly 30–50% or more, depending on the dose. They're among the most studied drugs in medicine and reduce heart attacks, strokes, and cardiovascular death in people at elevated risk. Most are generic and cost very little.
What about side effects?
- Muscle aches are the most-discussed side effect. But in blinded trials, people report nearly as many muscle symptoms on placebo as on the statin. In one trial where people alternated between statin, placebo, and nothing, about 90% of the symptoms also appeared on placebo. Real statin muscle symptoms do happen in a minority, and switching drugs, lowering the dose, or dosing a few times a week often solves them. Serious muscle damage is rare.
- A small increase in blood sugar, mostly in people already close to diabetes. The heart benefit generally outweighs this.
- Liver enzyme changes are occasionally seen. Serious liver injury is very rare.
- Large studies have not shown that statins cause memory loss or reduce testosterone in a clinically meaningful way.
If you stopped a statin because of side effects, it's worth talking to your doctor about trying a different one or a lower dose.
Beyond statins
| Drug | How it works | Typical LDL drop |
|---|---|---|
| Ezetimibe | A daily pill that blocks cholesterol absorption in the gut. Cheap, generic, often added to a statin. | ~20–25% |
| PCSK9 inhibitors (evolocumab, alirocumab) | Injections every 2–4 weeks. Very effective for high-risk patients or those who can't reach target. | ~50–60% |
| Inclisiran | A twice-yearly injection in a clinic after the first two doses, working on the same pathway as PCSK9 inhibitors. | ~50% |
| Bempedoic acid | A daily pill, an option for people who can't tolerate statins. | ~15–25% |
For very high triglycerides, prescription omega-3 (icosapent ethyl) may be used alongside a statin in people at high risk.
TRT & cholesterol
At standard replacement doses, TRT usually has small effects on cholesterol. A modest drop in HDL is the most common change. Above-normal doses, and oral anabolic steroids in particular, can crash HDL and raise LDL dramatically, one reason bodybuilding-style use is so hard on the heart.
If you're on TRT, get a lipid panel with your routine follow-up labs. TRT risks & side effects →