How to lower your LDL cholesterol
LDL is the cholesterol that builds plaque in your arteries. The lower it stays, the lower your risk of a heart attack or stroke. Here is how to find your goal, what diet and supplements can and cannot do, and how each medicine works.
From Dr. Kenneth Civello, MD, MPH, cardiologist and electrophysiologist
Know your goal
Your LDL goal depends on your risk. The 2026 guideline brought back clear number goals.
We estimate your chance of a heart attack or stroke over the next 10 years with a tool called PREVENT. It uses your age, blood pressure, cholesterol, blood sugar, kidney function, and smoking. Then we set a goal.
| Your situation | LDL goal |
|---|---|
| No heart disease, low risk (under 3 percent) | Healthy habits. Medicine is usually not needed. |
| No heart disease, borderline or intermediate risk (3 to under 10 percent) | Under 100 |
| No heart disease, high risk (10 percent or more) | Under 70 |
| Heart disease: a heart attack, stent, bypass, stroke, or known plaque | Under 70 |
| Heart disease plus other high risk features | Under 55 |
Diabetes, kidney disease, a very high LDL, and a strong family history can move you into a higher group.
Where a calcium score fits
A coronary calcium score is a quick CT scan that shows calcium in the heart arteries. Calcium means plaque is there. When it is not clear whether you need medicine, the score helps us decide. Any calcium supports a goal under 100, and a higher score calls for a lower goal. A score of zero may mean you can wait. Plaque analysis goes further and measures soft plaque that a calcium score can miss.
Lp(a) and ApoB
Patients ask me about these two tests more than any others. Here is what each one tells us.
Lp(a), or lipoprotein little a
A type of LDL particle that is extra sticky. Your level is set mostly by your genes. Diet and exercise barely change it. The 2026 guideline says every adult should have it checked once.
ApoB
ApoB counts the number of particles that can build plaque. LDL measures how much cholesterol they carry. Most of the time the two agree. When they do not, ApoB is the better guide.
What a high Lp(a) means
A level of 125 nmol/L or more, or 50 mg/dL or more, raises your risk of heart attack and stroke. At 250 nmol/L, the risk is about double. Labs report it in either unit, and the two do not convert neatly, so look at which one your report uses. There is no approved medicine made just for Lp(a). In September 2026, a large trial of one Lp(a) drug lowered the level but did not lower heart attacks or strokes. Others are still being tested. For now, a high Lp(a) means we lower your LDL harder and treat your blood pressure and other risks earlier. Your parents, brothers and sisters, and children should be checked too.
Who should have ApoB checked
ApoB helps most when you have diabetes, high triglycerides, extra weight around the middle, or known plaque. It also helps when your LDL is at goal but your risk still seems high. If your ApoB stays high, we may add medicine even though your LDL looks good.
Diet and daily habits
Food changes can lower LDL a little. They lower your overall heart risk a lot.
- Swap saturated fat from butter, fatty meat, and cheese for olive oil, nuts, seeds, avocado, and fish.
- Eat more fiber. Oats, beans, lentils, and barley carry the kind that lowers LDL.
- Use a paper filter for coffee. French press and boiled coffee can raise LDL.
- Move most days, keep a healthy weight, and do not smoke.
Some people eat well and still have a high LDL because of their genes. That is not a failure. It is a reason for medicine. Eating for your heart.
Supplements
The 2026 guideline recommends against using supplements to lower cholesterol. The studies show little or no LDL drop compared with even a low dose statin.
Here is what I tell patients about the ones they ask about. Some of them I do use, for people at lower risk who cannot take or do not want medicine. I never use them in place of medicine when your risk is high.
Psyllium
A gel forming fiber, the kind in Metamucil. It lowers LDL a little and helps blood sugar and regularity. I count it as food more than a supplement.
Citrus bergamot
An extract from a citrus fruit grown in Italy. Small studies show a modest LDL drop. There are no trials showing fewer heart attacks, and products vary. I sometimes use it for people at lower risk who will not take a statin.
Red yeast rice
It works because it contains a natural statin. The amount varies from bottle to bottle, and some contain a toxin. It is not safer than a statin. If you want a statin, take a real one at a known dose.
Fish oil
It does not lower LDL. A prescription form, icosapent ethyl, is a different product we use for some people with high triglycerides.
Plant sterols, garlic, turmeric, berberine
Little or no LDL effect in good studies. Berberine can interact with other medicines.
Niacin and CoQ10
Niacin added to a statin did not prevent heart attacks and has side effects. CoQ10 has not been shown to ease statin aches, though it is safe to try.
Tell us about every supplement you take. Some interact with heart medicines.
Statins
Statins are the first medicine for high LDL. They have the strongest proof of preventing heart attacks and strokes.
A statin tells your liver to make less cholesterol and to pull more LDL out of your blood. A moderate dose lowers LDL by about 30 to 49 percent. A high dose lowers it by about half or more. Common ones are atorvastatin, rosuvastatin, and pravastatin. Most are cheap generics taken once a day.
What about muscle aches?
Aches are the most common reason people stop. In a trial where people took a statin, a placebo, and nothing in turn without knowing which, most of the aches came with the placebo too. Real statin aches do happen. If you have them, tell us. We can lower the dose, switch statins, or take it every other day. Very few people truly cannot take any statin.
Do statins raise blood sugar?
A little, in some people. People already close to diabetes may cross the line sooner. The drop in heart attacks and strokes is much larger than this risk, so we keep the statin and watch your sugar.
Statins and memory
Many people worry that a statin will hurt their memory or cause dementia. The evidence does not show that.
In 2012, the FDA added a note to statin labels about rare reports of memory problems or confusion. These reports were not common, and they went away when people stopped the statin. Since then, large trials have tested memory in people taking statins or placebo. People on statins did no worse. Long studies of large groups have found that people on statins are not more likely to get dementia. Some found a lower risk.
Very low LDL from other medicines has not hurt memory either. In a trial that tested memory in people taking Repatha, they did as well as people on placebo.
Do not just stop it. Tell us. We look for other causes, like poor sleep, low thyroid, or other medicines. If needed, we can try a different statin or another medicine.
Why plaque matters for memory too
Plaque and high blood pressure in the brain's blood vessels raise the risk of strokes, including small ones you may not feel. Those small strokes are a common cause of memory loss in older age. Protecting your arteries protects your brain as well as your heart.
When a statin is not enough
If your LDL is still above goal, or you cannot take a statin, we add one of these.
Ezetimibe (Zetia)
A daily pill that blocks cholesterol from food in your gut. It lowers LDL by about 20 to 25 percent and adds to a statin. It is cheap, generic, and rarely causes side effects. It is usually the first thing I add.
Bempedoic acid (Nexletol)
A daily pill that works in the liver like a statin, but not in muscle, so it rarely causes aches. It lowers LDL by about 15 to 25 percent. In people who could not take statins, it lowered heart attacks. It can raise uric acid and trigger gout. It also comes combined with ezetimibe as Nexlizet.
PCSK9 inhibitors (Repatha, Praluent)
A shot under the skin, every two weeks or once a month, that you give yourself. It lowers LDL by about 60 percent, and it lowers heart attacks and strokes. It lowers Lp(a) somewhat too. Insurance often needs paperwork first.
Inclisiran (Leqvio)
A shot given in the office. After the first two doses, you need it only twice a year. It lowers LDL by about 50 percent. Trials to prove it lowers heart attacks are still under way.
These can be combined. Many people reach their goal with a statin and ezetimibe. People with very high LDL or known plaque often need a shot.
Plan your numbers
Pick your situation, enter your LDL, and see about how far each medicine could take you. Nothing you enter leaves this device.
These are typical drops from studies. Your own response may be larger or smaller. If you already take a medicine, enter your LDL from before you started it, or count only what you would add.
Common questions
How often should I check my cholesterol?
About 4 to 12 weeks after you start or change a medicine, then every 3 to 12 months while you are on it. Fasting is usually not needed.
Can I stop my statin once my numbers are good?
No. Your numbers are good because of the statin. LDL goes back up within weeks of stopping. Ask us before you change anything.
My LDL is high, but I eat well. Why?
Your genes set much of your LDL. Some families carry a gene that keeps LDL very high from childhood, called familial hypercholesterolemia. An LDL of 190 or more, or early heart disease in the family, is a reason to look for it.
Do I need a statin if my calcium score is zero?
Often you can wait, unless you have diabetes, smoke, have a strong family history, or have a very high LDL or Lp(a). A score of zero does not rule out soft plaque, so we look at the whole picture.
Is there a medicine for high Lp(a)?
Not yet. Several are being tested. One failed to lower heart attacks in 2026. For now, we lower your LDL and your other risks more firmly. PCSK9 inhibitors lower Lp(a) somewhat as a bonus.
Is very low LDL safe?
Yes, in the trials so far. People who reached LDL levels in the 20s and 30s had fewer heart attacks and no more side effects, including memory problems.
This page is general education for my patients. It does not replace advice from your own doctor.
Based on: 2026 ACC/AHA/Multisociety Guideline on the Management of Dyslipidemia. J Am Coll Cardiol. 2026. Lloyd-Jones DM, et al. 2022 ACC Expert Consensus Decision Pathway on the Role of Nonstatin Therapies for LDL Cholesterol Lowering. J Am Coll Cardiol. 2022. Newman CB, et al. Statin Safety and Associated Adverse Events: A Scientific Statement From the American Heart Association. Arterioscler Thromb Vasc Biol. 2019. Wood FA, et al. N of 1 Trial of a Statin, Placebo, or No Treatment to Assess Side Effects. N Engl J Med. 2020. Laffin LJ, et al. Comparative Effects of Low Dose Rosuvastatin, Placebo, and Dietary Supplements on Lipids and Inflammatory Biomarkers. J Am Coll Cardiol. 2023. Cannon CP, et al. Ezetimibe Added to Statin Therapy after Acute Coronary Syndromes. N Engl J Med. 2015. Nissen SE, et al. Bempedoic Acid and Cardiovascular Outcomes in Statin Intolerant Patients. N Engl J Med. 2023. Sabatine MS, et al. Evolocumab and Clinical Outcomes in Patients with Cardiovascular Disease. N Engl J Med. 2017. Giugliano RP, et al. Cognitive Function in a Randomized Trial of Evolocumab. N Engl J Med. 2017. Schwartz GG, et al. Alirocumab and Cardiovascular Outcomes after Acute Coronary Syndrome. N Engl J Med. 2018. US Food and Drug Administration. Important safety label changes to cholesterol lowering statin drugs. 2012.