What is High LDLc?

"Present clinicians need to place less emphasis on lipid levels

 and more importance on risk stratification of the patient. 2018"

Chart below from 2009

More recent guidelines before 2017

UPDATE  May 2018

With Odyssey, Fournier and REAL-CAD the concept of what is a normal LDLc has changed.  LDLc should be viewed in terms of risk factors. 

Nice summary 2002 link

MedGenMed. 2002 Dec 10;4(4):1.

Protecting the heart: a practical review of the statin studies.

Ong HT1.

Author information

Abstract

The aim of this review of the landmark HMG-CoA reductase inhibitors (statins) studies is to enable the clinician to draw practical lessons from these trials.

1- The Scandinavian Simvastatin Survival Study (4S) established the importance of treating the hypercholesterolemic patient with established cardiovascular heart disease.

 2-The West of Scotland Coronary Prevention Study (WOSCOPS) showed the benefit of treating healthy hypercholesterolemic men who were nevertheless at high risk of developing cardiovascular heart disease in the future. 

3-The Cholesterol and Recurrent Events (CARE) study, a secondary prevention trial, proved the benefit of treating patients with myocardial ischemia and cholesterol levels within normal limits. This conclusion was confirmed by

4- the Long-term Intervention With Pravastatin in Ischemic Disease (LIPID) study, another secondary prevention study that enrolled patients with a wide range of cholesterol levels (4-7 mmol/dL), into which the large majority of patients would belong.

 The importance of treating patients with established ischemic heart disease (IHD), and those at high risk of developing cardiovascular heart disease, regardless of cholesterol level, was being realized. 

5-The Air Force/Texas Coronary Artery Prevention Study (AFCAPS/TexCAPS) then showed that treatment can reduce adverse cardiovascular events even in the primary prevention of patients with normal cholesterol levels.

6- The Myocardial Ischemia Reduction With Aggressive Cholesterol Lowering (MIRACL) trial showed that hypocholesterolemic therapy is useful in the setting of an acute coronary syndrome, while the 

7-Atorvastatin Versus Revascularisation Treatment (AVERT) study showed that aggressive statin therapy is as good as angioplasty in reducing ischemic cardiac events in patients with stable angina pectoris. 

8-Finally, the Heart Protection Study (HPS) randomized more than 20,000 patients, and the value of statins in reducing adverse cardiovascular events in

A) the high-risk patient, including

B) the elderly,

C )women, and 

D) even in those with low cholesterol levels,is beyond doubt. 

The emphasis is now on the risk level for developing cardiovascular events, and treatment should target the high-risk group and not be dependent on the actual cholesterol level of the patient.

 It is interesting to compare the large amount of data on the value and safety of the statins

 with the much more limited and less convincing data on antioxidant vitamins.

2018 Protecting the heart: a practical review of the statin studies.  Sorry have to join Medscape but it is free.

I copied  2018 "Conclusion

It is important to seek useful lessons for the practicing physician from these statin trials on hyperlipidemia. 

The beneficial effect of statin therapy in reducing adverse cardiovascular events, as well as reducing coronary mortality and total mortality in high-risk patients, is overwhelming.

 There has to be a change in emphasis away from the concept of a "normal lipid profile." 

Instead, the emphasis should be on risk factors predisposing to coronary disease. 

The actual threshold for the initiation of therapy varies, but the principle remains the same.^{[13,14,15,50]} 

The higher the risk, assessed from

1- prior atheromatous disease,

2- diabetes, 

3-blood pressure, 

4-smoking status, 

5-age, and 

6-sex, 

besides the lipid levels, the greater the need to treat and to treat aggressively.

Whether statins work by reducing lipid levels or by plaque stabilization or an anti-inflammatory effect is a matter for future researchers to resolve. 

Present clinicians need to place less emphasis on lipid levels

 and more importance on risk stratification of the patient.

 Indeed, a case can be made for all patients with a prior atheromatous disease to be on a statin, regardless of their initial cholesterol level. 

Equally important, extrapolating especially from the primary prevention trials, the patient not at high risk of cardiovascular events should not be treated merely because of an abnormal lipid profile,

 as there will not be any significant mortality reduction."