High LDL cholesterol is an important cardiovascular risk factor. Over time, greater exposure to LDL cholesterol contributes to the development of atherosclerosis.
But does a very high LDL cholesterol level mean that plaque is already present in the arteries of the heart?
Not necessarily.
A 2024 analysis from the Miami Heart Study examined 1 808 adults aged 40–65 who had no cardiovascular symptoms and were not taking statins. Researchers used CT imaging to look directly for atherosclerotic plaque in the coronary arteries.
Among participants with LDL cholesterol of 190 mg/dL or higher, 40% had no detectable coronary plaque.
This finding does not mean that very high LDL cholesterol is harmless.
LDL cholesterol contributes to atherosclerosis over time. A person without detectable plaque today may still have substantial long-term cardiovascular risk if exposure to high LDL cholesterol continues.
The study therefore shows an important difference between a cardiovascular risk factor and the amount of disease already present.
A blood test measures LDL cholesterol circulating in the blood. It cannot directly show whether plaque has already developed in the coronary arteries.
For this reason, LDL cholesterol should be interpreted together with age, blood pressure, smoking, diabetes, family history and other factors that influence cardiovascular risk.
