What should I do for patients younger than 40 who have zero to two risk factors for coronary artery disease (CAD) and LDL 130-160 mg/dL if they have not responded to lifestyle modifications?
—Derek Olson, DO, Chicago

There is no simple answer to this question. It depends what the “risk factors” are. For example, a strong family history of premature CAD combined with diabetes and an LDL of 160 would push me toward statin therapy. Conversely, no risk factors and an LDL of 135 would lead me to advocate even more work on lifestyle changes. The “promise of LDL lowering therapy for primary and secondary prevention” is discussed by Grundy (Circulation. 2008;117:569-573) as part of the “Controversies in Cardiovascular Medicine Section” and is worth reading. The one absolute rule all would agree on: Smoking must not be tolerated in any patient with elevated LDL.
—Peter F. Cohn, MD