I recently had a slim and fit sixty-something year old lady come in for a discussion on her elevated cholesterol. While her total and LDL-cholesterol were notably high, her protective HDL-cholesterol levels were elevated as well in a satisfying sort of way.

The first step in determining whether or not she should be on cholesterol-lowering meds involved totaling up her risk factors for coronary artery disease according to guidelines issued by the National Cholesterol Education Program(1):
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Major Risk Factors (Exclusive of LDL Cholesterol) That Modify LDL Goals

* Cigarette smoking
* Hypertension (BP greater than or equal to140/90 mmHg or antihypertensive medication
* Low HDL cholesterol (<40 mg/dl)*
* Family history of premature CHD (CHD in male first degree relative <55 years; CHD in female first degree relative <65 years)
* Age (men greater than or equal to45 years; women greater than or equal to55 years)

* HDL cholesterol greater than or equal to60 mg/dL counts as a "negative" risk factor; its presence removes one risk factor from the total count.
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According to our calculations in her situation, she had zero risk factors as her HDL-cholesterol of 87 canceled out her age of 62. Her goal LDL-cholesterol was less than 60, and the recommended level at which to use medication was greater than 190.

Her LDL-cholesterol was 197. She, as so many people are, was reluctant to start drug therapy. Off she went, instead, to Colorado Heart & Body Imaging for a $395 CT scan of her heart. The news was not good--she had a fair amount of calcifications in her coronary arteries, correlating with more plaque in those vessels than 90% of women her age.

She started treatment with Lipitor yesterday.

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1. See NHLBI, ATP III At-A-Glance for the complete algorithm.