A high cholesterol reading may be a wake-up call, but whether medication is needed depends on more than the number alone.
High cholesterol, like diabetes and hypertension (high blood pressure), can often have no symptoms, meaning a person may not realise they have the condition.
Consultant cardiologist Dr Lim Bee Chian says this is why assessing a person’s overall cardiovascular risk is important when deciding how to manage cholesterol.
He explains that treatment depends on a patient’s starting low-density lipoprotein (LDL) cholesterol level, overall cardiovascular risk and the target they need to reach.
For some people, improving their diet and exercising more may be enough to bring their LDL cholesterol towards the desired level.
For others, lifestyle changes alone may not be enough.
Numbers to aim for
The same LDL cholesterol number can mean different things for different people.
A person’s overall cardiovascular risk depends on a combination of factors, including age, sex, family history and genetics, smoking, obesity, physical inactivity, diabetes, and hypertension.
This means two people with similar cholesterol readings may not necessarily have the same level of cardiovascular risk – or require the same treatment approach.
“After you know the number, you can have an assessment of the total risk – whether this patient belongs to low, moderate, high or very high risk.
“And from there, you know what is the LDL target you’re aiming for,” says Dr Lim.
The LDL cholesterol target becomes progressively lower as cardiovascular risk increases.
“For low risk, we keep the LDL less than 3 mmol/L.
“Moderate, below 2.6.
“High risk would be below 1.8, alongside a reduction of at least 50% from baseline,” he notes.
For people at very high cardiovascular risk, the target is even lower – at 1.4 mmol/L or below – while also aiming for at least a 50% reduction from baseline.
Very high-risk patients include those who already have cardiovascular disease, such as people who have heart disease or had a stroke.
For these patients, keeping LDL cholesterol low is aimed at preventing further build-up in the arteries and reducing the risk of another cardiovascular event.
“You might survive the first heart attack, but you might not survive the second or the third heart attack.
“Because any time you’ve a heart attack, a portion of the heart muscle actually dies off,” warns Dr Lim.
He stresses that prevention is preferable to trying to limit the damage after a heart attack has already occurred.
Based on calculations
Once the LDL cholesterol target is set, the next question is how much it needs to fall and whether lifestyle changes alone can get it there.
For lower-risk patients, lifestyle changes such as diet and exercise may be enough.
Dr Lim says patients should give lifestyle changes at least three months before assessing whether they are working, using blood tests and weight as indicators.
“You’ve got to look at the weight, hence why you need at least three months.”
Medication, however, can lower LDL cholesterol more quickly, with results typically seen within about a month.
This may be needed for patients whose LDL cholesterol is too high or whose cardiovascular risk is too great for lifestyle changes alone to achieve the target.
Dr Lim says lifestyle changes can reduce LDL cholesterol by about 30% at most.
“Let’s say your baseline is 4.8.
“Even if you follow your diet and exercise religiously, you can only drop it by about 30%.
“That’s a reduction of 1.6, so your LDL cholesterol would come down to 3.2.
“But for a very high-risk patient, 3.2 is still far above the target of 1.4.
“Hence, you need to add on the medication up front.”
Cholesterol-lowering treatment typically starts with a statin.
For patients who need a greater reduction, additional drugs may be added.
“We always start with the statin,” he says.
“But if you know from the calculation, even with the high-intensity statin, you cannot achieve that, then you add on the second agent.
“If that still doesn’t achieve our target, then you have to add on the injectable agent.”
One such option is a PCSK9 inhibitor, which helps the liver to clear cholesterol faster.
“Once we agree on the target LDL, we agree on the treatment plan, we’ll carry on the treatment for life,” says Dr Lim.
However, lifelong treatment does not necessarily mean the dose will always remain the same.
The treatment plan can be adjusted depending on how the patient’s LDL cholesterol responds and their overall circumstances.
If lifestyle improvements bring LDL cholesterol substantially lower than expected, the doctor may consider reducing the medication dose after reviewing the patient’s progress.
Dr Lim also stresses that diet and exercise remain important even when medication is prescribed, as part of managing cholesterol and overall cardiovascular risk.
Cut the bad, increase the good
Even when medication is prescribed, managing heart health involves more than lowering LDL cholesterol alone.
Dr Lim stresses that treatment should address a person’s overall cardiovascular risk, rather than focusing solely on their cholesterol level.
“If you’ve got three risk factors, you’ve got to address them all together,” he says.
“That’s why we need holistic treatment.
“And all this can be achieved by diet, exercise and medication.”
Clinical dietitian and Sunway Medical Centre Dietetics & Nutrition Services assistant director Celeste Lau says that dietary changes do not have to be drastic to make a difference.
She explains: “For heart health, eating habits are actually about small changes.
“But when you are consistent, they all actually grow.”
Rather than trying to eliminate multiple foods at once, she recommends reducing saturated and trans fats, which can raise LDL cholesterol, while making room for heart-healthy foods.
She says: “A lot of times when we talk to patients, they will just try to cut down the bad things.
“But sometimes, you find the problem may actually be more about taking less of the good things, like fish, vegetables and soluble fibre.”
Her advice is to focus on changes that can be maintained over time, rather than following overly restrictive diets that may be difficult to sustain.
“Besides cutting down the bad things, always remember to have more good things in your life,” she says.
Lau also stresses that dietary needs and cholesterol levels can differ from person to person.
Two people may eat similar foods but have different cholesterol levels because of differences in genetics, medical history and lifestyle.
Being consistent
Cholesterol treatment is not a pick-and-choose process.
Dr Lim shares that some patients may choose to take statins intermittently after hearing negative claims about them from friends or on social media.
“They say they are going to adhere to the prescription, but then they don’t,” he says.
He cautions that taking statins inconsistently can cause LDL cholesterol levels to fluctuate, making it harder to keep under control.
He stresses that patients should take their medication consistently: “If you are going to take the medicine, you take it every day.
“Sometimes you might miss one dose and that is quite common.
“But the aim is to keep LDL cholesterol levels as stable as possible.”
Dr Lim adds that once cholesterol has contributed to plaque build-up in the artery wall, treatment is primarily aimed at preventing the plaque from progressing.
“Once they go inside the vessel wall, they are trapped inside.
“They will never come out again,” he stresses.
While some small studies have reported plaque regression among patients who reach their cholesterol targets with medication, Dr Lim says any regression is quite negligible.
“Even if you take your medicine religiously and you hit the target, the most you can expect is that the plaque remains status quo.”
Given this, he emphasises the importance of follow-up consultations, with patients reviewed within one to three months after starting treatment to assess whether it is working, they are taking the medication as prescribed, and experiencing any side effects.
Dr Lim and Lau, as well as Sunway Medical Centre physiotherapist Natalie Goh, were speaking at a media roundtable held in conjunction with World Heart Day (2026).
