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Biomarker library / Lipids

LDL cholesterol (LDL-C)

Also called low-density lipoprotein cholesterol, "bad" cholesterol

The cholesterol carried in low-density lipoprotein particles, usually calculated from a standard lipid panel. LDL particles deposit cholesterol in artery walls, which is why LDL-C is the number most cholesterol treatment decisions are keyed to.

Written by the VitalDecades editorial team Reviewed by the editorial review process Updated

01  /  Reference ranges

What counts as normal

Scale in mg/dL. Cut points from the sources listed below.
Population Adults (ATP III classification)
Category Optimal
Range under 100 mg/dL
Source NCEP Adult Treatment Panel III, Executive Summary (NHLBI, 2001)

Effective

Population Adults (ATP III classification)
Category Near optimal / above optimal
Range 100 to 129 mg/dL
Source NCEP Adult Treatment Panel III, Executive Summary (NHLBI, 2001)

Effective

Population Adults (ATP III classification)
Category Borderline high
Range 130 to 159 mg/dL
Source NCEP Adult Treatment Panel III, Executive Summary (NHLBI, 2001)

Effective

Population Adults (ATP III classification)
Category High
Range 160 to 189 mg/dL
Source NCEP Adult Treatment Panel III, Executive Summary (NHLBI, 2001)

Effective

Population Adults (ATP III classification)
Category Very high
Range 190 or higher mg/dL
Source NCEP Adult Treatment Panel III, Executive Summary (NHLBI, 2001)

Effective

Population Adults, any age (2018 AHA/ACC decision threshold)
Category Severe primary hypercholesterolemia: high-intensity statin, no risk score needed
Range 190 or higher mg/dL
Source 2018 AHA/ACC Multisociety Guideline on the Management of Blood Cholesterol

Effective

Population Adults 40 to 75, primary prevention (2018 AHA/ACC)
Category Risk-discussion band; statin decision by 10-year ASCVD risk
Range 70 to 189 mg/dL
Source 2018 AHA/ACC Multisociety Guideline on the Management of Blood Cholesterol

Effective

Population Very high-risk ASCVD on a statin (2018 AHA/ACC)
Category Threshold to consider adding ezetimibe, then a PCSK9 inhibitor
Range 70 or higher mg/dL
Source 2018 AHA/ACC Multisociety Guideline on the Management of Blood Cholesterol

Effective

Population Very high CV risk (2019 ESC/EAS goal)
Category LDL-C goal
Range under 55 mg/dL And at least a 50% reduction from baseline.
Source 2019 ESC/EAS Guidelines for the management of dyslipidaemias

Effective

Normal vs optimal

"Normal" on a lab report usually means the ATP III optimal band, under 100 mg/dL. Treatment targets are lower for people who already have cardiovascular disease: the 2018 AHA/ACC guideline uses 70 mg/dL as the very-high-risk threshold, and the 2019 ESC/EAS guideline sets goals of under 55 mg/dL for very-high-risk and under 70 for high-risk patients. Which number applies to you depends on your risk category, not on the lab's reference interval.

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02  /  Why it matters

What the number tells you

Two documents govern how LDL-C is read in the US. The NCEP Adult Treatment Panel III (2001) categories are what most lab reports still print: optimal under 100 mg/dL, near optimal 100 to 129, borderline high 130 to 159, high 160 to 189, very high 190 and above. The 2018 AHA/ACC multisociety guideline does not use those bands for decisions; it uses thresholds. An LDL-C of 190 mg/dL or higher means high-intensity statin therapy without a risk calculation. Between 70 and 189 mg/dL, adults 40 to 75 have a risk discussion keyed to their 10-year ASCVD risk. In people at very high risk who are already on a statin, 70 mg/dL is the threshold to consider adding a non-statin.

03  /  In practice

Testing and what moves it

When it is tested

  • As part of a lipid panel; the USPSTF ties statin decisions to adults 40 to 75 with risk factors, and the 2018 AHA/ACC guideline suggests risk assessment from age 20 with lipids every 4 to 6 years in adults free of disease.
  • Fasting is no longer required for a screening lipid panel in most cases; very high triglycerides can distort a calculated LDL-C.

What raises it

  • Saturated and trans fat intake, genetics (familial hypercholesterolemia is the classic cause of LDL-C 190 or above), hypothyroidism, nephrotic syndrome, some medications.

What lowers it

  • Statins, ezetimibe, PCSK9 inhibitors and other lipid-lowering drugs; dietary change (less saturated fat, more soluble fiber); weight loss has a modest effect.

04  /  Related

Read next

Apolipoprotein B ApoBHDL cholesterol HDL-CHigh-sensitivity C-reactive protein hs-CRPTriglycerides TG

Frequently asked questions

Is 130 mg/dL LDL high? ▼

ATP III labels 130 to 159 mg/dL borderline high. Under the 2018 AHA/ACC guideline, whether it needs treatment depends on your 10-year ASCVD risk and risk-enhancing factors, not on the band alone.

Why do some doctors want LDL under 70 or under 55? ▼

Those are treatment thresholds and goals for people at very high cardiovascular risk: 70 mg/dL in the 2018 AHA/ACC guideline, under 55 mg/dL in the 2019 ESC/EAS guideline. They are not the reference range for a healthy adult without disease.

Do I need to fast for an LDL test? ▼

Usually not for screening. If triglycerides are very high, a fasting sample or a direct LDL measurement gives a more reliable LDL-C.