LDL cholesterol: read your lipid test and lower your risk

A result to read in light of your risk

When there is too much of it, cholesterol builds up in the arteries and raises the risk of heart attack and stroke. In Belgium, 47% of adults have a total cholesterol above 190 mg/dL, and only one in three people with a high level knows it (Sciensano, 2018). But the same result does not mean the same thing for everyone: it all depends on your overall risk.

What a lipid test measures

• Total cholesterol: all the cholesterol in the blood.
• LDL cholesterol (“bad cholesterol”): the kind that builds up in the arteries; it is the main target of treatment.
• HDL cholesterol (“good cholesterol”): it is used in the risk calculation.
• Triglycerides: other blood fats, sensitive to sugar, alcohol and weight.
• Non-HDL cholesterol (total minus HDL): all the particles that damage the arteries; this is the value SCORE2 uses.
• Lipoprotein(a) or Lp(a): a particle similar to LDL, more than 90% determined by genetics. The European ESC/EAS guidelines suggest measuring it at least once in adult life. Above 50 mg/dL (105 nmol/L), it increases risk.

Fasting is usually not necessary; follow the instructions you are given. In Anderlecht, the blood test can be done at the practice or at home by our nursing team.

Why there is no single “normal” value

Each 1 mmol/L (about 39 mg/dL) reduction in LDL lowers major cardiovascular events by about 22% over 5 years. The gain therefore depends on your starting risk: according to the 2025 European update, the same reduction brings a 20% risk down to 16%, but a 10% risk only down to 8%. The higher the risk, the lower the target.

Without known cardiovascular disease, this risk is estimated with SCORE2 (ages 40 to 69) or SCORE2-OP (ages 70 to 89): the probability of a heart attack, stroke or cardiovascular death within 10 years, based on age, sex, smoking, blood pressure and non-HDL cholesterol. Belgium uses the version calibrated for “low-risk countries”. Estimate yours with our SCORE2 tool, then discuss it with your doctor. SCORE2 does not apply if you have cardiovascular disease, diabetes, chronic kidney disease or familial hypercholesterolaemia, or if you are already on cholesterol-lowering treatment.

Risk categories and LDL targets

The 2025 ESC/EAS focused update defines the categories using SCORE2, but the 2019 targets have not changed:

• Very high risk (heart attack, stroke, peripheral artery disease, stent or bypass, significant plaque on imaging, diabetes with organ damage, severe kidney failure, SCORE2 of 20% or more): LDL below 55 mg/dL and a reduction of at least 50%. After a second event within two years, a target below 40 mg/dL may be considered.
• High risk (LDL above 190 mg/dL, familial hypercholesterolaemia alone, diabetes for 10 years or more, moderate kidney failure, SCORE2 of 10 to 20%): LDL below 70 mg/dL and a reduction of at least 50%.
• Moderate risk (SCORE2 of 2 to 10%): LDL below 100 mg/dL.
• Low risk (SCORE2 below 2%): LDL below 116 mg/dL.

These can move you up a category: early cardiovascular disease in the family, high Lp(a), obesity, physical inactivity, chronic inflammatory disease, early menopause. Blood pressure matters too: read our article on high blood pressure.

Familial hypercholesterolaemia: when to think of it?

This genetic condition affects about one person in 200 to 250. Without treatment, it often leads to coronary heart disease before age 55 in men and 60 in women. Talk to your doctor if:

• your LDL is above 190 mg/dL without treatment;
• you or a relative had heart disease at a young age;
• you or a relative have cholesterol deposits on the tendons (xanthomas);
• a relative already has this diagnosis.

Treatment starts early, and relatives, including children, are screened.

Lifestyle: the foundation, but a modest effect on LDL

• Replace saturated fats (butter, processed meats, cheese, pastries) with olive or rapeseed oil, nuts and fish.
• Eat fibre: 3 to 10 g a day of beta-glucans (oats, barley) lower LDL by 3 to 5%.
• Foods enriched with plant sterols (2 g a day) lower it by 7 to 10%.
• Moving for 30 minutes a day and, if overweight, losing 5 to 10% of your weight mainly improve triglycerides and HDL.
• Limit alcohol and sugary drinks; stop smoking.

Dietary supplements are not recommended. Red yeast rice contains a natural statin in variable amounts: it does not replace treatment and must not be combined with a statin.

Medication: statins first

Statins are the first choice: they reduce heart attacks, strokes and mortality, with few serious side effects. They lower LDL by 30 to 50%, or by at least 50% at high intensity. At low risk, the absolute gain is small: the decision is made together. If the target is not reached or statins are not tolerated:

• ezetimibe adds a 21 to 27% LDL reduction to a statin;
• bempedoic acid lowers LDL by about 23% on its own and 18% with a statin; it is recommended when statins cannot be taken;
• other treatments (PCSK9 inhibitors, inclisiran) are reserved for specific situations, usually with specialist advice.

Statin side effects and the nocebo effect

Statins can cause muscle pain or a usually temporary rise in liver enzymes, and slightly increase the risk of type 2 diabetes. Severe muscle damage (rhabdomyolysis) is rare: 1 to 3 cases per 100,000 patients per year. Always mention your other medicines. Statins are not recommended during pregnancy and breastfeeding.

In 19 double-blind trials (nearly 124,000 participants), 27.1% of people on a statin and 26.6% on placebo reported muscle pain or weakness: more than 90% of these complaints were not caused by the statin. In the SAMSON trial, 60 people who had stopped their statin because of side effects alternated between statin, placebo and months without tablets: 90% of the symptoms felt on the statin were also present on placebo. This is the “nocebo effect”: expecting a side effect is enough to trigger it.

If you have pain, do not stop on your own: talk to your general practitioner. They may pause treatment, measure CK (a muscle enzyme), then try another statin or a lower dose. Report severe pain or unusual weakness quickly; outside opening hours, call the GP on duty at 1733.

How often should it be checked?

• Before treatment: usually two tests 1 to 12 weeks apart, except at very high risk.
• After starting or changing treatment: a check after about 8 weeks (4 to 12), until the target is reached.
• Target reached: once a year.

When to call 112?

Chest pain, weakness on one side of the body or difficulty speaking: call 112 immediately. Child who has swallowed tablets: Poison Centre, 070 245 245. At Maison Médicale Parc Astrid in Brussels, we set realistic goals with you.

Sources

• ESC/EAS – Focused Update dyslipidaemias (2025)
• ESC/EAS – Guidelines dyslipidaemias (2019)
• CBIP/BCFI – Belgian drug formulary, 1.12 Lipid-lowering drugs (2026)
• Sciensano – Belgian Health Examination Survey 2018 (2019)
• Belgian Society of Atherosclerosis – Louvain Médical (2024)
• The Lancet – CTT, statin therapy and muscle symptoms (2022)
• NEJM – SAMSON trial, statin or placebo (2020)