What “not enough” actually means
Most people with high cholesterol have no symptoms, and the NHS is clear that it is diagnosed on a blood test and nowhere else. The only signal that treatment has fallen short is a number on a printout.
The number to compare it against comes from NICE guideline NG238, published on 14 December 2023, last reviewed on 2 September 2025, and replacing CG181 from July 2014. For secondary prevention, meaning people who have already had a cardiovascular event, NG238 sets a target of LDL cholesterol at 2.0 mmol/L or below, or non-HDL cholesterol at 2.6 mmol/L or below. NICE estimated the guideline would prevent between 50,000 and 145,000 cardiovascular events over ten years.
Being above target is not unusual. The Health Survey for England 2021 part 2, published on 16 May 2023, found that 59 percent of adults in England had total cholesterol of 5 mmol/L or above, and 72 percent of those aged 45 to 64. The British Heart Foundation reports that high LDL cholesterol is associated with around 1 in 5 cardiovascular disease deaths in the UK, and that cardiovascular disease causes around 170,000 deaths a year, 26 percent of all UK deaths.
Step one: the statin gets reviewed before anything is added
The BHF puts the range plainly: a low dose of a statin lowers LDL cholesterol by up to about 30 percent, and a high dose by more than 40 percent. A low dose leaves headroom before a second medicine is needed.
The BHF states that research has found statins do not cause most of the side effects commonly reported. Muscle pain is a genuine side effect and it is uncommon. Some statins carry a small risk of type 2 diabetes.
Most people need to take a statin long term, because cholesterol rises again once it is stopped unless that is combined with sustained lifestyle change. Lifestyle change helps, though the BHF notes it does not work for everyone, and familial hypercholesterolaemia requires drug treatment regardless of diet.
Step two: ezetimibe
NICE TA385, published on 24 February 2016, recommends ezetimibe in two situations:
- as an add-on to a statin, where the statin alone has not brought cholesterol to target
- on its own, where statins are contraindicated or not tolerated
That second line matters for anyone who came off statins and assumed that was the end of the options.
Step three: bempedoic acid with ezetimibe
NICE TA694, published on 28 April 2021, recommends bempedoic acid with ezetimibe for primary hypercholesterolaemia or mixed dyslipidaemia, where statins are contraindicated or not tolerated and ezetimibe on its own has not been enough.
NICE TA805, from 2022, recommends icosapent ethyl to reduce cardiovascular risk in people with raised triglycerides who already take a statin. It is the single exception NICE makes to its general advice against offering omega-3 compounds for this purpose.
Step four: the injections, and the funding myth to ignore
A claim circulates online, including on UK health pages, that PCSK9 inhibitors are not available on the NHS. That is wrong, and it has been wrong for a decade.
Alirocumab (TA393) and evolocumab (TA394) were both published by NICE on 22 June 2016 and both are recommended on the NHS for defined groups, subject to commercial access agreements. NHS.uk’s own medicines page, last reviewed on 13 March 2026, lists alirocumab and evolocumab alongside ezetimibe and bempedoic acid.
Access depends on LDL cholesterol staying above a threshold despite maximal tolerated lipid-lowering therapy. TA393 gives these examples:
- above 3.5 mmol/L in people at very high risk with established cardiovascular disease
- above 4.0 mmol/L in people at high risk without a prior event
- above 5.0 mmol/L in familial hypercholesterolaemia without cardiovascular disease
If your last LDL result sits above one of those numbers on maximum tolerated therapy, that is a specific conversation to have with your GP or lipid clinic.
Inclisiran, and why the criteria are narrower
NICE TA733, published on 6 October 2021, covers inclisiran, an siRNA treatment funded centrally by NHS England. Its criteria are tighter. Two conditions must be met together: a history of a cardiovascular event, and LDL cholesterol persistently at 2.6 mmol/L or above despite maximum tolerated lipid-lowering therapy.
The qualifying events are acute coronary syndrome, revascularisation, coronary heart disease, ischaemic stroke and peripheral arterial disease. In people with no history of cardiovascular disease, NICE recommends inclisiran only in a research context, and not for routine NHS use.
NG238 cross-references TA385, TA393, TA394, TA694 and TA733 as the routes to escalate when statins and ezetimibe are not enough.
Two things a standard cholesterol test will not tell you
Familial hypercholesterolaemia affects around 1 in 250 people in the UK, roughly 270,000 people. NICE CG71, published on 27 August 2008 and last updated on 4 October 2019, covers diagnosis, including cascade testing of relatives. Family history is one of the risk factors the NHS lists, alongside being over 50, being male, being post-menopausal, and South Asian or sub-Saharan African ethnicity.
The second is lipoprotein(a). It is inherited and genetically determined, a standard NHS cholesterol test does not measure it, and HEART UK estimates roughly 1 in 5 people have elevated levels. Statins do not lower it and no licensed treatment to lower it exists. NG238 does not currently contain lipoprotein(a) recommendations. We cover this in more detail in our article on Lp(a) and inherited heart risk.
If you have also been told you have fat in your liver, our piece on MASH, fatty liver disease without alcohol explains what that diagnosis involves.
Where clinical research fits
Clinical trials are one route among several. They run alongside the NHS ladder and replace no part of it.
Studies in lipid lowering generally compare an investigational treatment against an approved treatment, or against a placebo added to the therapy a participant already takes. Eligibility is written into the sponsor’s protocol, so a site cannot widen or narrow it. A screening visit determines eligibility. Taking part is voluntary and a participant may withdraw at any time, and study-related assessments and monitoring are provided as part of the trial.
If none of the approved steps has brought your number to target, asking your GP whether any research is recruiting is a reasonable question to add to the list.
Frequently asked questions
Can I get a PCSK9 inhibitor like evolocumab on the NHS?
Yes. Alirocumab and evolocumab have been NICE-recommended and NHS funded since 22 June 2016, under TA393 and TA394. Access depends on LDL cholesterol staying above a set threshold despite maximal tolerated lipid-lowering therapy, for example above 3.5 mmol/L with established cardiovascular disease.
What should my cholesterol be if I have already had a heart attack?
NICE NG238 sets a secondary prevention target of LDL cholesterol at 2.0 mmol/L or below, or non-HDL cholesterol at 2.6 mmol/L or below. That guideline was published on 14 December 2023 and last reviewed on 2 September 2025. Your own target should be confirmed by the clinician managing your treatment.
What can I take if I cannot tolerate statins?
Ezetimibe can be taken alone where statins are contraindicated or not tolerated, under NICE TA385. If ezetimibe alone is not enough, TA694 recommends bempedoic acid with ezetimibe for the same group. PCSK9 inhibitors are also assessed on maximal tolerated therapy, which can include no statin at all.
Who can have inclisiran on the NHS?
Inclisiran is recommended under NICE TA733 only for people who have a history of a cardiovascular event and whose LDL cholesterol is persistently at 2.6 mmol/L or above despite maximum tolerated lipid-lowering therapy. Qualifying events include acute coronary syndrome, revascularisation, coronary heart disease, ischaemic stroke and peripheral arterial disease.
Does a normal cholesterol test measure Lp(a)?
No. A standard NHS cholesterol test does not measure lipoprotein(a), which is inherited and genetically determined. HEART UK estimates roughly 1 in 5 people have elevated levels. Statins do not lower it, and there is no licensed treatment to lower it. NICE NG238 does not currently contain lipoprotein(a)-specific recommendations.
Do I have to stay on a statin for life?
Most people do need to take a statin long term. The British Heart Foundation explains that cholesterol rises again once a statin is stopped, unless that is combined with sustained lifestyle change. Familial hypercholesterolaemia needs drug treatment regardless of diet.
About Panthera
Panthera Biopartners is a Site Management Organisation running commercial clinical trials at seven UK clinics, in Glasgow, Enfield, Keele, Preston, Rochdale, Sheffield and York. It does not design protocols or set eligibility criteria, and it does not conduct first-in-human studies. You can read about current recruitment on our high cholesterol clinical trial page.
Disclaimer
Not medical advice. This article is general information about UK treatment pathways for high cholesterol. Do not start, stop or change any medicine without speaking to your GP, pharmacist or specialist.
Conflicts and affiliations. Panthera Biopartners runs clinical trials, including studies relating to high cholesterol. Discuss whether a trial is suitable for you with your own clinician and with the study team before consenting to anything.
