LDL Cholesterol

At a Glance

Why Get Tested?

To determine your risk of developing heart disease; to monitor effectiveness of lipid-lowering therapy

When To Get Tested?

Screening: as part of a health exam with a lipid panel; every four to six years in adults with no risk factors for heart disease; youth should be tested at least once between the ages of 9 and 11 and once again between the ages of 17 and 21

Monitoring: may be done more frequently and at regular intervals when risk factors for heart disease are present, when prior results showed high risk levels, and/or when undergoing treatment for unhealthy lipid levels

Sample Required?

A blood sample drawn from a vein in your arm or from a fingerstick

Test Preparation Needed?

Laboratory tests for LDL-C typically require a 9 to 12-hour fast, but your healthcare practitioner may decide that you may be tested without fasting. In particular, youths (ages 2 to 24) without risk factors may have testing done without fasting. Follow any instructions you are given and tell the person drawing your blood whether or not you have fasted.

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What is being tested?

Low-density lipoprotein is a type of lipoprotein that consists of cholesterol (LDL cholesterol, LDL-C) and similar substances with a small amount of protein. Testing for LDL-C often involves using a formula to calculate the amount of LDL-C in blood based on results of a lipid panel. Sometimes, LDL-C is measured directly.

Monitoring and maintaining appropriate levels of cholesterol and other lipids is important for staying healthy. A diet high in saturated fats and trans unsaturated fats (trans fats), or an inherited predisposition can result in a high level of cholesterol in the blood. The extra cholesterol may be deposited in plaques on the walls of blood vessels. Plaques can narrow or eventually block the opening of blood vessels, leading to hardening of the arteries (atherosclerosis) and increased risk of numerous health problems, including heart disease and stroke.

High LDL-C is considered to be undesirable and LDL-C is often called “bad” cholesterol because it is associated with cholesterol plaques, atheroslcerosis, and heart disease. This is in contrast to high-density lipoproteins (HDL) that tend to transport cholesterol from the arteries to the liver. High HDL-C is thought to protect against heart disease and so it is often called “good” cholesterol.

Common Questions

How is the test used?

The test for low-density lipoprotein cholesterol (LDL-C) is used as part of a lipid panel to estimate your likelihood of developing heart disease. If you have borderline, intermediate or high risk, results of the LDL-C test and other components of the lipid panel are considered along with other known risk factors of heart disease to develop a plan of treatment and follow-up. Treatment options may include lifestyle changes such as diet or exercise programs or lipid-lowering drugs such as statins. LDL-C test may be also used to monitor whether treatment has been effective in lowering cholesterol levels.

LDL-C is often not measured directly but is instead calculated from other components of the lipid panel, including total cholesterol, HDL cholesterol (HDL-C), and triglycerides (see below for the most commonly-used formula). In most cases, this calculation provides a good estimate of LDL-C, but it becomes less accurate in patients with triglyceride levels above 400 mg/dL, severe cirrhosis, and other conditions. For these individuals, accurate determination of LDL-C can be done with direct LDL-C tests or special testing techniques (e.g., beta quantification).

When is it ordered?

Many health organizations recommend that all adults with no other risk factors for heart disease be tested with an LDL-C test as part of a fasting lipid panel every four to six years.

If you have risk factors for heart disease (see below) or if previous testing showed that you had undesirable results, more frequent testing with a fasting lipid panel is recommended.

Examples of risk factors for heart disease include:

Cigarette smoking
Being overweight or obese
Unhealthy diet
Being physically inactive, not getting enough exercise
Age (males 45 years or older or females 55 years or older)
High blood pressure (blood pressure of 140/90 or higher or taking high blood pressure medications)
Family history of premature heart disease (heart disease in a first degree male relative under age 55 or a first degree female relative under age 65)
Pre-existing coronary heart disease or a previous heart attack
Diabetes or prediabetes

Children, teens and young adults (ages 2 to 24 years old) with no risk factors should have a lipid panel done once between the ages of 9 and 11 and again between the ages of 17 and 21, according to the American Academy of Pediatrics (AAP).

Youths with an increased risk of heart disease as adults should have earlier and more frequent screening with lipid panels. Some of the risk factors are similar to those in adults and include a family history of heart disease or health problems such as diabetes, high blood pressure, or being overweight. High-risk children should be tested between 2 and 8 years old with a fasting lipid panel, according to the AAP. Children younger than 2 years old are too young to be tested.

Monitoring

LDL-C levels, either alone or as part of lipid panels, may also be ordered at regular intervals to evaluate the success of lipid-lowering lifestyle changes such as diet and exercise or to determine the effectiveness of drug therapy such as statins.

What does the test result mean?

In general, healthy lipid levels help to maintain a healthy heart and lower the risk of heart attack or stroke. Your healthcare practitioner will take into consideration the results of the LDL-C and the other components of a lipid panel as well as other risk factors to help determine your overall risk of heart disease, whether treatment is necessary and, if so, which treatment will best help to lower your risk.

Adults

Health organizations have different recommendations for treatment based on your predicted cardiovascular disease (CVD) risk.

Current guidelines from the American College of Cardiology (ACC) and the American Heart Association (AHA) recommend that a risk calculator be used to determine your 10-year risk of CVD if you are age 40 to 75 and do not have heart disease. Many factors are considered in the calculation, including total cholesterol, LDL-C, HDL-C, age, gender, race, blood pressure, diabetes, and smoking.

ACC and AHA recommend treatment with statins if you:

Have heart disease (diagnosed by medical history, imaging, etc.)
Have LDL-C greater than 190 mg/dL (4.90 mmol/L)
Are age 40 to 75 years with diabetes and LDL-C 70-189 mg/dL (1.81-4.90 mmol/L)
Are age 40 to 75 years old with LDL-C level between 70-189 mg/dL (1.81-4.90 mmol/L) and 10-year risk of developing heart disease of greater than 7%

The U.S. Preventive Services Task Force (USPSTF) makes recommendations on the use of statins for treatment in adults ages 40 to 75 with no history of heart disease, based on risk factors (i.e., LDL-C greater than 130 mg/dL [3.37 mmol/L], HDL-C less than 40 mg/dL [1.0 mmol/L], diabetes, blood pressure, smoking) and the use of the risk calculator.

If you have one or more risk factors and a calculated 10-year CVD event risk of 10% or greater, USPSTF recommends the use of a low-to-moderate dose statin.
If you have one or more risk factors and your calculated 10-year CVD event risk is 7.5% to 10%, USPSTF says your healthcare practitioner may choose to offer a low-to-moderate dose statin. This is because the probability that you will have a CVD event is lower, so the benefit of statin is likely to be smaller.

According to the USPSTF, there is not currently enough evidence to evaluate the utility of screening adults ages 21 to 39 for unhealthy lipid levels, or to assess the benefits and risks of statin use in adults 76 years or older with no history of CVD.

Use of the risk calculator and ACC/AHA guidelines remains controversial and is evolving as more data become available. Some say that the current risk calculator can overestimate risk. Many still use the older guidelines (2002) from the NCEP Adult Treatment Panel (ATP) III to evaluate LDL-C levels and heart disease risk, as summarized below.

Optimal	Near/Above Optimal	Borderline High	High	Very High
Less than 100 mg/dL (2.59 mmol/L); with CVD or diabetes: less than 70 mg/dL (1.81 mmol/L)	100-129 mg/dL (2.59-3.34 mmol/L)	130-159 mg/dL (3.37-4.12 mmol/L)	160-189 mg/dL (4.15-4.90 mmol/L)	Greater than 190 mg/dL (4.90 mmol/L)

According to NCEP ATP III guidelines, if you have LDL-C above the following target values and risk factors (e.g., family history, cigarette smoking, diabetes, high blood pressure), you require treatment.

The target LDL-C values are:

Less than 100 mg/dL (2.59 mmol/L) if you have heart disease or diabetes [and ideally less than 70 mg/dL [1.81 mmol/L)]
Less than 130 mg/dL (3.37 mmol/L) if you have 2 or more risk factors
Less than 160 mg/dL (4.14 mmol/L) if you have 0 or 1 risk factor

Youth

According to the American Academy of Pediatrics, the LDL-C level can be evaluated for youth with no other risk factors as follows:

	Acceptable	Borderline	High
Children and Teens (ages 2 to 18)	Less than 110 mg/dL (2.85 mmol/L)	110-129 mg/dL (2.85-3.34 mmol/L)	Greater than or equal to 130 mg/dL (3.36 mmol/L)
Young Adults (ages 19 to 24)	Less than 120 mg/dL (3.10 mmol/L)	120-159 mg/dL 3.10-4.11 mmol/L)	Greater than or equal to 160 mg/dL (4.12 mmol/L)

Low levels of LDL cholesterol are not generally a concern and are not monitored. They may be seen in people with an inherited lipoprotein deficiency and in people with hyperthyroidism, infection, inflammation, or cirrhosis.

What treatments are recommended for high LDL-C levels?

Maintaining a healthy lifestyle is an important part of heart health and in treating high LDL-C. This may mean you will need to change your lifestyle, specifically by adopting a diet low in saturated fat and trans unsaturated fats (trans fats), avoiding smoking, controlling high blood pressure and diabetes, achieving and maintaining desirable body weight, and getting regular exercise. You may be referred to a dietician for advice in making dietary changes.

Your healthcare practitioner will talk to you about risks and benefits of lipid-lowering therapy, based on your history, health risks, the results of your lipid panel, and possibly your calculated risk for CVD. Statins are generally recommended as a first choice for lowering LDL-C. You may be prescribed one of these. Your LDL-C will be checked at regular intervals to make sure that the drug is working. If your LDL-C is above target levels, your healthcare practitioner may increase the amount of drug, change drugs, or possibly add a second drug.

Can I test my LDL cholesterol at home?

There are tests available to use at home to measure total cholesterol. You prick your finger and put blood on a piece of paper that will change color based on your cholesterol level (or use your blood and a small device to do the same thing).

There are also kits available that have you collect a blood sample at home and then mail it to a reference laboratory, which will perform a lipid panel and send the results back to you.

What is the formula used to calculate LDL-C?

The formula most often used by laboratories is called the Freidewald formula, though some research suggests it’s not the most accurate formula and some recommend using other formulas instead. The Freidewald formula uses the results from the components of the lipid panel that are measured directly. In the U.S., units are in mg/dL and the formula can only be applied if total triglycerides are less than 400 mg/dL:

LDL cholesterol = Total cholesterol – HDL cholesterol – (Total triglycerides/5)

What is a direct LDL cholesterol test?

The direct low-density lipoprotein cholesterol test (direct LDL-C) is an actual measurement of the amount of LDL cholesterol in your blood. Usually, your LDL-C level is calculated using the measured values of the components of a standard lipid panel. In most cases, calculated LDL-C is a good estimate of the LDL-C, but it becomes less accurate with increasing triglyceride levels. A direct LDL-C may be ordered by your healthcare practitioner when prior test results have indicated high triglycerides. In some laboratories, the direct LDL-C test will automatically be performed when the triglyceride levels are too high to calculate LDL-C.

What is LDL particle testing?

LDL particle testing (LDL-P) is additional testing that may be used to help estimate your risk of cardiovascular disease (CVD). This is a test that measures the number of LDL particles, rather than measuring the amount of LDL cholesterol. For many people, the LDL-C test is a good indicator of risk of CVD, but research has found that some people with healthy levels of LDL-C still have increased risk of CVD. Similarly, individuals with some chronic conditions such as diabetes may have increased risk even though their LDL-C is at a healthy level. For these populations, it has been suggested that the number of LDL particles and/or their size might be an additional factor to consider when determining their CVD risk. For more on this, see the article on LDL Particle Testing.

Is there anything else I should know?

LDL-C should be measured when you are not ill. LDL-C is temporarily low during acute illness, immediately following a heart attack, or during stress (like from surgery or an accident). Wait at least six weeks after any illness to have LDL-C measured.

Certain types of prescription drugs may raise or lower LDL-C levels. Inform your healthcare provider of any drugs or supplements that you are taking before testing.

In women, LDL-C usually rises during pregnancy. Women should wait at least six weeks after having a baby to have LDL-C measured.

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Lab Tests Online is an award-winning patient education website offering information on laboratory tests. The content on the site, which has been reviewed by laboratory scientists and other medical professionals, provides general explanations of what results might mean for each test listed on the site, such as what a high or low value might suggest to your healthcare practitioner about your health or medical condition.

The reference ranges for your tests can be found on your laboratory report. They are typically found to the right of your results.

If you do not have your lab report, consult your healthcare provider or the laboratory that performed the test(s) to obtain the reference range.

Laboratory test results are not meaningful by themselves. Their meaning comes from comparison to reference ranges. Reference ranges are the values expected for a healthy person. They are sometimes called “normal” values. By comparing your test results with reference values, you and your healthcare provider can see if any of your test results fall outside the range of expected values. Values that are outside expected ranges can provide clues to help identify possible conditions or diseases.

While accuracy of laboratory testing has significantly evolved over the past few decades, some lab-to-lab variability can occur due to differences in testing equipment, chemical reagents, and techniques. This is a reason why so few reference ranges are provided on this site. It is important to know that you must use the range supplied by the laboratory that performed your test to evaluate whether your results are “within normal limits.”

For more information, please read the article Reference Ranges and What They Mean.

Health Professionals – LOINC

LOINC Observation Identifiers Names and Codes (LOINC®) is the international standard for identifying health measurements, observations, and documents. It provides a common language to unambiguously identify things you can measure or observe that enables the exchange and aggregation of clinical results for care delivery, outcomes management, and research. Learn More.

Listed in the table below are the LOINC with links to the LOINC detail pages. Please note when you click on the hyperlinked code, you are leaving Lab Tests Online and accessing Loinc.org.

LOINC	LOINC Display Name
91105-7	Cholesterol in LDL 1 [Mass/Vol]
91112-3	Cholesterol in LDL 1 [Moles/Vol]
91106-5	Cholesterol in LDL 2 [Mass/Vol]
91113-1	Cholesterol in LDL 2 [Moles/Vol]
91107-3	Cholesterol in LDL 3 [Mass/Vol]
91114-9	Cholesterol in LDL 3 [Moles/Vol]
91108-1	Cholesterol in LDL 4 [Mass/Vol]
91115-6	Cholesterol in LDL 4 [Moles/Vol]
91109-9	Cholesterol in LDL 5 [Mass/Vol]
91116-4	Cholesterol in LDL 5 [Moles/Vol]
91110-7	Cholesterol in LDL 6 [Mass/Vol]
91117-2	Cholesterol in LDL 6 [Moles/Vol]
91111-5	Cholesterol in LDL 7 [Mass/Vol]
91118-0	Cholesterol in LDL 7 [Moles/Vol]
18261-8	Cholesterol in LDL (S/P ultracentrifugate) [Mass/Vol]
2089-1	Cholesterol in LDL [Mass/Vol]
13457-7	Cholesterol in LDL Calc [Mass/Vol]
18262-6	Cholesterol in LDL Direct assay [Mass/Vol]
55440-2	Cholesterol in LDL VAP [Mass/Vol]
14155-6	Cholesterol in LDL [%]
22748-8	Cholesterol in LDL [Moles/Vol]
39469-2	Cholesterol in LDL Calc [Moles/Vol]
69419-0	Cholesterol in LDL Direct assay [Moles/Vol]
96258-9	Cholesterol in LDL Calculated by Martin-Hopkins [Moles/Vol]
96259-7	Cholesterol in LDL Calculated by Martin-Hopkins [Mass/Vol]
96597-0	Cholesterol in LDL Direct assay (DBS) [Mass/Vol]

View Sources

Sources Used in Current Review

Nordestgaard, Børge G., Langsted, Anne, Mora, Samia, et al. (2016 July 1). Fasting Is Not Routinely Required for Determination of a Lipid Profile: Clinical and Laboratory Implications Including Flagging at Desirable Concentration Cut-points—a Joint Consensus Statement from the European Atherosclerosis Society and European Federation of Clinical Chemistry and Laboratory Medicine. European Heart Journal. Available online at https://doi.org/10.1093/eurheartj/ehw152. Accessed September 2019.

Grundy, Scott M., Stone NJ, Bailey AL, et al. (2018 November 10) 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. Available online at https://www.ahajournals.org/doi/10.1161/CIR.0000000000000625. Accessed September 2019.

LDL: The “Bad” Cholesterol. U.S. National Library of Medicine. Available online at https://medlineplus.gov/ldlthebadcholesterol.html. Accessed September 2019.

Fernandez-Friera, L., Fuster, V., Lopez-melgar B. et al. (2017 December). Normal LDL-Cholesterol Levels Are Associated With Subclinical Atherosclerosis in the Absence of Risk Factors. Journal of the American College of Cardiology. Available online at http://www.onlinejacc.org/content/70/24/2979. Accessed September 2019.

Singh N., Kumar, B J, Thimmaraju, K V, et al. (2017 January). Anandaraja Formula or Friedewald Formula, which is a Better Formula for Calculating LDL Cholesterol in Comparison with Direct LDL – Measurement by Homogenous Assay Method. International Journal of Contemporary Medical Research. Available online at https://www.ijcmr.com/uploads/7/7/4/6/77464738/ijcmr_1228_feb_18.pdf. Accessed September 2019.

Krishnaveni, P., Gowda, V. (2015 December 1). Assessing the Validity of Friedewald’s Formula and Anandraja’s Formula For Serum LDL-Cholesterol Calculation. Journal of Clinical & Diagnostic Research. Available online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4717736/. Accessed September 2019.

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American Heart Association. Numbers That Count for a Healthy Heart. Available online at http://www.americanheart.org.

Pagana K, Pagana T. Mosby’s Manual of Diagnostic and Laboratory Tests. 3rd Edition, St. Louis: Mosby Elsevier; 2006 pp 351-357.

National Heart, Lung, Blood Institute. National Cholesterol Education Program Guidelines, Cholesterol, ATP III (online information). Available online at http://www.nhlbi.nih.gov. Accessed February 2008.

Henry’s Clinical Diagnosis and Management by Laboratory Methods. 21st ed. McPherson R, Pincus M, eds. Philadelphia, PA: Saunders Elsevier: 2007.

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Hayashi T, et. al. Importance of Lipid Levels in Elderly Diabetic Individuals—Baseline Characteristics and 1-Year Survey of Cardiovascular Events. Cir J 2008; 72:218—225.

American Academy of Pediatrics. 7 Jul 2008. AAP issues new guidelines on cholesterol screening (press release). Available online at http://www.aap.org/new/july08lipidscreening.htm. Accessed August 2008.

Pagana K, Pagana T. Mosby’s Manual of Diagnostic and Laboratory Tests. 4th Edition, St. Louis: Mosby Elsevier; 2010, Pp 356-363.

Van Leeuwen A.M., Poelhius-Leth, D.J. Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests With Nursing Implications. 3rd Edition, Philadelphia: F.A. Davis Company; 2009, Pp 325-329.

National Heart, Lung, and Blood Institute of the National Institutes of Health, United States Department of Health and Human Services. ATP III Update 2004: Implications of Recent Clinical Trials for the ATP III Guidelines. Bethesda, Md. 2004 May. Available online at http://www.nhlbi.nih.gov/guidelines/cholesterol/atp3upd04.htm.

(Updated 2011 August 2). Mayo Clinic. High Cholesterol [Online Information]. Available online at http://www.mayoclinic.com/health/high-blood-cholesterol/DS00178. Accessed August 2011.

(Updated 2010 May 23). MedlinePlus Medical Encyclopedia. LDL Test [Online information]. Available online at http://www.nlm.nih.gov/medlineplus/ency/article/003495.htm. Accessed August 2011.

Vujovic A, et al. Evaluation of Different Formulas for LDL-C Calculation. Lipids Health Dis, 2010; 9: 27. Abstract available online at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2847568/. Accessed Sept. 2011.

Davidson M, et al. Clinical Utility of Inflammatory Markers and Advanced Lipid Testing: Advice from an Expert Panel of Lipid Specialists. Journal of Clinical Lipidology 2011 Sep; 5(5): 338-67.

Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Sep 2002. PDF available for download at http://www.nhlbi.nih.gov/guidelines/cholesterol/atp3full.pdf. Accessed October 2012.

(November 2012) American Association of Family Physicians. High Cholesterol. Available online at http://familydoctor.org/familydoctor/en/diseases-conditions/high-cholesterol.html. Accessed October 2012.

Kavey R-EW, et al. Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents: Summary report. Pediatrics 2011; 128: DOI:10.1542/peds.2009-2107C. PDF available for download at http://pediatrics.aappublications.org/site/misc/2009-2107.pdf. Accessed October 2012.

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(2006) Sekar K. Increased Small Low-Density Lipoprotein Particle Number, A Prominent Feature of the Metabolic Syndrome in the Framingham Heart Study. Circulation. Available online at http://circ.ahajournals.org/content/113/1/20.full. Accessed October 2012.

(September 23, 2002) Blake G, et al. Low-Density Lipoprotein Particle Concentration and Size as Determined by Nuclear Magnetic Resonance Spectroscopy as Predictors of Cardiovascular Disease in Women. Circulation, Available online at http://circ.ahajournals.org/content/106/15/1930.full. Accessed October 2012.

Blakenstein R, et al. Predictors of Coronary Heart Disease Events Among Asymptomatic Persons With Low Low-Density Lipoprotein Cholesterol. Journal of the American College of Cardiology Volume 58, Issue 4, 19 July 2011, Pp 364–374.

Krauss R. Lipoprotein subfractions and cardiovascular disease risk. Curr Opin Lipidol 2010 Aug;21(4):305-11. Abstract available online at http://www.ncbi.nlm.nih.gov/pubmed/20531184. Accessed October 2012.

Prado K, et al. Low-density lipoprotein particle number predicts coronary artery calcification in asymptomatic adults at intermediate risk of cardiovascular disease. J Clin Lipidol 2011 Sep-Oct;5(5):408-13. Abstract available online at http://www.ncbi.nlm.nih.gov/pubmed/21981843. Accessed October 2012.

(May 2012) Lavie C, et.al. To B or Not to B: Is Non–High-Density Lipoprotein Cholesterol an Adequate Surrogate for Apolipoprotein B? Mayo Clin Proc. 2010 May; 85(5): 446–450. Available online at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2861974/. Accessed October 2012.

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Stone N.J. et al. (2013 November 12). 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults. Circulation 10.1161/01.cir.0000437738.63853.7. Available online at https://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437738.63853.7a. Accessed on 5/01/16.

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