What are the specific LDL-C thresholds in the 2025 ACC/AHA cholesterol guideline for starting statins at different 10-year ASCVD risk levels?

1. What the reporting actually says about starting statins: the one undeniable rule — LDL‑C ≥190 mg/dL

All summaries and guideline‑focused pieces in the search results confirm that severe hypercholesterolemia (LDL‑C ≥190 mg/dL, often expressed as ≥5.0 mmol/L) remains a clear indication to begin high‑intensity statin therapy without needing a 10‑year ASCVD risk calculation ^{[1] [6]}. Multiple sources repeat this as a longstanding, unchanged threshold for immediate statin initiation ^{[1] [6]}.

2. Where 10‑year risk thresholds are discussed — continuation of the pooled‑cohort approach, but no new LDL matrix found

Background articles reiterate the ACC/AHA paradigm of using pooled‑cohort 10‑year ASCVD risk categories (eg, low <5%, borderline 5–<7.5%, intermediate 7.5–20%, high ≥20%) to guide clinician–patient discussion on primary prevention and statin consideration, but the available 2025 materials in the search set do not provide a new LDL‑by‑risk table that specifies precise LDL‑C start points for each risk stratum ^{[4] [7]}. In short: risk bands are still central to decision making, but the documents provided do not map exact LDL cutoffs to every risk band ^{[4] [5]}.

3. Common LDL thresholds for intensification or adding nonstatins — 70 mg/dL and 55 mg/dL appear repeatedly

For patients already on maximally tolerated statin therapy (particularly secondary prevention/ASCVD and ACS populations), the literature repeatedly cites LDL‑C ≥70 mg/dL as the customary threshold to consider adding ezetimibe or other nonstatin agents, and some high‑risk or ACS guidance advises consideration of intensification even at LDL‑C in the 55–<70 mg/dL range ^{[6] [2] [3]}. The 2025 ACS guideline specifically recommends nonstatin agents when LDL‑C is ≥70 mg/dL on maximally tolerated statin, and states it is reasonable to intensify therapy when LDL‑C is 55 to <70 mg/dL in very high‑risk ACS patients ^[2].

4. Expert consensus and ECDPs continue to frame thresholds for adding nonstatins, but their aim differs from “start statin” rules

The 2022 ACC Expert Consensus Decision Pathway (and related 2025 commentaries) emphasize LDL‑C thresholds for when to add nonstatin therapies to existing statins (for example, using ≥70 mg/dL as a trigger in high‑risk patients) and discuss percent LDL reductions expected from statin intensities; these documents address intensification more than initial statin starts and are reflected in recent reviews ^{[8] [3]}. Thus, most cited cut points relate to escalation rather than changing the baseline 10‑year risk thresholds for starting a statin in primary prevention ^[8].

5. Where the gaps and disagreements are — no single source here lists LDL cutoffs tied to every risk band

The provided sources include guideline excerpts, editorials, and specialty statements that repeat core thresholds (≥190 mg/dL for immediate statin; ≥70 mg/dL and 55–70 mg/dL for intensification or adding nonstatins), but none supply a comprehensive 2025 ACC/AHA matrix specifying distinct LDL‑C thresholds for initiating statins at each 10‑year ASCVD risk level ^{[1] [2] [4]}. Therefore, asserting a new set of LDL thresholds by exact risk bands would go beyond the available reporting (not found in current reporting) ^{[4] [5]}.

6. Practical takeaway for clinicians and patients

Based on the documents available: start high‑intensity statin without 10‑year risk calculation when LDL‑C ≥190 mg/dL ^[1]; use pooled‑cohort 10‑year risk categories plus risk enhancers and shared decision‑making for primary prevention ^[4]; and consider adding nonstatin therapy when LDL‑C remains ≥70 mg/dL on maximal statin — and in very high‑risk/ACS patients, consider intensifying further even at 55–<70 mg/dL ^{[6] [2]}. If you need the precise 2025 ACC/AHA cholesterol guideline wording or a stepwise LDL × risk table, available sources do not include that consolidated table — you would need the full guideline document itself (not found in current reporting) ^{[2] [5]}.