How is the 51.9% for high cholesterol arrived at? Randomised statin data, whether Hong Kong has its own LDL target, and what the muscle-pain trials show, 2026

TL;DR The Department of Health's Population Health Survey report for the three years to 2022 (Part II) says that among people aged 15 to 84 the prevalence of raised blood cholesterol or hypercholesterolaemia is 51.9%. But that 51.9% is not "51.9% of Hong Kong adults need medication": it is 15.7% "self-reported as diagnosed by a doctor" plus 36.2% "measured total cholesterol ≥ 5.2 mmol/L" joined together, its age range is 15 to 84 rather than "adults", and 5.2 mmol/L is the upper end of what the Department of Health itself labels the "ideal level", not a threshold for prescribing. On low-density lipoprotein (LDL) the same report gives 41.0%, and on "either total cholesterol or LDL" 52.8% — three figures, not interchangeable. Another thing to be clear about: Hong Kong has no cholesterol treatment targets of its own. The government's reference framework series has seven sets — hypertension, diabetes, older adults, women, children, musculoskeletal problems and life-planning care — and no set for blood lipids; lipids appear only as "Module 9" appended to the hypertension reference framework, and that document states expressly that it merely lists several international guidelines "for reference" without adopting any of them. More important still: that document states that there is at present no cardiovascular risk assessment tool designed for Chinese populations, and that the American Pooled Cohort Equations show "Poor Calibration" for Hong Kong Chinese. One more thing worth saying first: a low score is not a discharge note. The British guideline that sets a ten-year risk threshold (NICE NG238) follows that threshold immediately with a prohibition — "Do not rule out treatment", that is, treatment must not be excluded merely because a score falls below the threshold; and the recommendation after that says treatment may be considered even at 85 or above. This article reproduces those two, but does not reproduce the threshold value. This article will not, and cannot, tell you whether to take medication, what target to set, or which drug to choose — those are for a doctor to decide on your circumstances. What it does is take apart how the official figures are composed, set out which standards Hong Kong has and which it does not, and say what the randomised controlled trials actually found about statins and muscle pain.

#What is cholesterol, and what do the lines on a lipid report each mean?

The abbreviations on a lipid report do not measure the same thing, and the Hong Kong government has published values for three of them, not all.

The Department of Health's Hong Kong Reference Framework for Hypertension Care for Adults [patient version] (revised July 2022) defines blood lipids as being made up mainly of triglycerides and cholesterol, and dyslipidaemia as an abnormal concentration of triglycerides or lipoproteins in the blood, a major risk factor for cardiovascular disease [Note 1].

In one sentence: a lipid test measures two broad classes of substance, triglycerides and cholesterol; and because cholesterol has to be carried in the blood by lipoproteins, what appears on the report are compound names such as "low-density lipoprotein cholesterol" and "high-density lipoprotein cholesterol".

Among the Hong Kong government documents cited here, only one publishes "ideal levels" for blood lipids to the public: the Centre for Health Protection's Cholesterol leaflet (revised 2025). (The same body's Non-Communicable Diseases Watch of October 2023 also printed values for the public, but of a different kind: the 5.2, 3.4, 1.0 / 1.3 and 1.7 there are the statistical cut-offs the Population Health Survey used to count proportions, not a table of "ideal levels". The two must not be treated as the same thing.)

Three things have to be said at once, because this table is easily misread.

One, there is no triglyceride (TG) row. The Centre for Health Protection's leaflet publishes no ideal level for triglycerides. The commonly seen "TG < 1.7" does not come from this document.

Two, the HDL row is the same for men and women — "above 1.0" for everyone, with 1.6 or above better. The Population Health Survey has a separate definition of "low high-density lipoprotein concentration" that is split by sex (women < 1.3, men < 1.0), but that is a statistical definition used to count prevalence, not a target the Centre for Health Protection gives the public. Two documents, two purposes, and they should not be run together.

Three, this table has no risk stratification at all. It is a reference value for the general population, and it is a completely different way of thinking from the "LDL target set by cardiovascular risk" discussed below.

The same leaflet's statement about dietary cholesterol is another distinction that is often skipped: although there is at present insufficient evidence on which to make a recommendation limiting dietary cholesterol intake, several medical organisations recommend that intake be as low as possible [Note 2]. And the two further points immediately after that sentence, within the same item 2, answer "what about eggs?" on the leaflet's own account: for healthy people, foods high in cholesterol but lower in fat such as eggs, squid, prawns and crabs should be counted within the intake of "meat, fish, eggs and alternatives" and eaten in moderation; and for dietary advice for individuals with high blood lipids or chronic disease, ask a healthcare professional [Note 2].

In other words: the government says itself that the evidence is not sufficient to set an upper limit on how much cholesterol to eat; but it does not stop there — within the same item it gives a way of handling it for healthy people, and for those who already have high blood lipids or a chronic illness it says expressly to ask a healthcare professional. So "the evidence is not sufficient to set a limit" is not "eat as much as you like", and it is not that the leaflet says nothing about eggs — it simply says two different things to two kinds of reader.

The same leaflet carries another sentence that settles the weighting of the whole section: saturated fat makes the blood clot more readily, leading to hardening of the arteries, stroke, heart disease and the like, and promotes the liver's production of cholesterol, raising the level of bad cholesterol in the blood, an ill effect greater than that of excessive dietary cholesterol intake [Note 3]. The leaflet's own ordering puts saturated fat first and dietary cholesterol second.

⚠ If you are holding a laboratory report and want to know what each line means, and which body set the figures in the "normal range" column: only this leaflet has published "ideal levels" to the public, and it covers three items, without triglycerides and without any risk stratification.

#"51.9% of Hong Kong people have high cholesterol" — how is that figure actually arrived at?

51.9% is a composite of two pieces of data, its age range is 15 to 84, and the laboratory cut-off folded into it is the upper end of an "ideal level", not a treatment threshold.

The original text of the summary of the Department of Health's Report of the Population Health Survey for the three years to 2022 (Part II, 2023) is at [Note 4]; the classification rule is at §3.2.2 of the same report: a participant whose measured total cholesterol was 5.2 mmol/L or above was defined as having hypercholesterolaemia [Note 5].

Do the arithmetic once (adding the official figures quoted above): self-reported as diagnosed by a doctor, 15.7%; no reported history but measured total cholesterol ≥ 5.2 mmol/L, 36.2%; 15.7% plus 36.2% is 51.9%. And the share who "do not know they have it" is 36.2 divided by 51.9, or 69.7%. The Centre for Health Protection's Non-Communicable Diseases Watch of October 2023 published a comparable proportion: that as many as 70% of people with raised cholesterol or hypercholesterolaemia were unaware of their condition and learnt of it only through the blood test provided in the survey — note the words "as many as", which state an upper bound rather than a point estimate.

That 51.9% has three properties that are easy to skip.

One, the age range is 15 to 84, not "adults". The base of the survey is all respondents aged 15 to 84 who took part in the physical examination, with a weighted population estimate of 5,959,700. Counting 15-year-olds and 16-year-olds under the same heading of "adults" will make a reader overestimate how common this is outside middle age.

Two, 5.2 mmol/L is the upper end of an "ideal level". The same government says in the Cholesterol leaflet that total cholesterol below 5.2 is the ideal level; and the Population Health Survey uses the same line to define hypercholesterolaemia. So people whose test exceeds 5.2 are counted into the 51.9%, but that does not amount to any document saying that above 5.2 means treatment.

Three, the same report has three prevalence figures on three different bases, and the values are far apart.

All three figures come from the same report and the same respondents. The differences come purely from which analyte and which cut-off. Cite one of them without saying which basis, and the reader cannot know what they are looking at.

The same report has another figure counting laboratory results only and age-standardised, on yet another cut-off: among people aged 18 to 84, the age-standardised prevalence of total cholesterol ≥ 5.0 mmol/L (regardless of known history) was 45.0% (crude rate 49.7%), with a mean total cholesterol of 5.0 mmol/L. Note that the cut-off here is 5.0 rather than 5.2, so this 45.0% and the 51.9% above cannot be subtracted from one another and cannot be set side by side.

One last point, and it runs against intuition: the age curve for blood lipids does not simply rise. The Population Health Survey records that the proportion with total cholesterol ≥ 5.2 mmol/L rises from 15.0% at ages 15 to 24 to 57.4% at ages 55 to 64, and then falls back to 40.5% at ages 65 to 84; the composite prevalence likewise peaks at 55 to 64 (72.1%). That is unlike the blood pressure curve, which keeps rising with age, so the inference that "as the population ages, lipid problems must become ever more common" does not hold for lipids.

⚠ If a headline saying "more than half of Hong Kong people have high cholesterol" has you wondering whether you are one of them, or your report says total cholesterol 5.3 and you want to know what that means: 5.2 is the upper end of an ideal level and a statistical cut-off, not a treatment threshold in any Hong Kong document.

#"From 8.4% to 51.9% in 20 years" — why does that sentence not hold?

Because 8.4% and 51.9% measure two different things: the 2003-04 survey did no blood lipid testing at all.

The 8.4% comes from a 2024 commentary in the Hong Kong Medical Journal (Yan BPY and others, Hong Kong Med J 2024;30:90–3), the original text of which is at [Note 6]. And the 8.4% in the 2003/04 Population Health Survey (English executive summary) means that about one in twelve reported having been diagnosed with high blood cholesterol by a doctor [Note 7] — that is, purely a self-reported, doctor-diagnosed proportion. That survey did no lipid testing, so there is no "found on testing" component to correspond with the 36.2% of 2020-22.

The comparisons that can be made are these two series:

Do the arithmetic once (subtracting the figures in the table above): self-reported diagnosis rose from 8.4% to 15.7%, a rise of 7.3 percentage points, close to a doubling. Composite prevalence rose from 49.5% (2014/15) to 51.9% (2020-22), a rise of 2.4 percentage points.

In other words: what rose steeply is the proportion diagnosed; while the proportion with actually abnormal lipids, measured with the same ruler, moved by a little over two percentage points in six to eight years. The distinction matters, because the two point to different conclusions — one is "more testing", the other is "more disease".

Incidentally, the same 2024 commentary contains a unit error elsewhere in its text (writing mmol/L as "mmol/dL"). That is worth knowing before citing any figure from it. Its narrative observations about the treatment gap in Hong Kong (underuse of statins in diabetic patients, and undertreatment particularly of women and younger people) remain within the scope of the studies it cites.

⚠ If you have seen a headline about "a 6-fold rise in 20 years" and think Hong Kong people's lipids have suddenly deteriorated: that comparison puts two differently defined figures on the same line.

#Why do doctors look at LDL more than at total cholesterol?

Because the relationship between lowering LDL and reducing cardiovascular events is the most consistent piece of evidence there is — while total cholesterol is a sum of several components.

Total cholesterol includes LDL, HDL and other components. Someone with high HDL and someone with high LDL can have the same total cholesterol and a different clinical meaning.

The Cholesterol Treatment Trialists' Collaboration's 2012 meta-analysis of individual participant data from 27 randomised trials (Lancet 2012;380:581-90) included individual participant data from 22 trials of statin versus control, n = 134,537, with a mean LDL cholesterol difference of 1.08 mmol/L and a median follow-up of 4.8 years; per 1.0 mmol/L reduction in LDL, the rate ratio for major vascular events was 0.79 (95% confidence interval 0.77–0.81), and largely irrespective of age, sex, baseline LDL or previous vascular disease [Note 8].

The same analysis also published the absolute benefit in the low-risk group: in individuals with a five-year risk of major vascular events below 10%, each 1 mmol/L reduction in LDL produced an absolute reduction in major vascular events of about 11 per 1000 over five years [Note 9].

Do the arithmetic once (converting the 11 per 1000 quoted above): 11 fewer major vascular events per 1000 people over five years; 1000 divided by 11 is about 91 — so about 91 low-risk people would have to receive treatment equivalent to a 1 mmol/L LDL reduction for five years to avoid one event. Put the other way: the other 90 or so will not have their outcome changed by that treatment over those five years. These are two sides of the same figure, and both have to be said.

And the three sentences the authors themselves wrote immediately after that figure, within the same passage, run in the opposite direction from "90 people take it for nothing", so this article reproduces them too [Note 10]: this benefit greatly exceeds any known hazards of statin therapy; under present guidelines, such individuals would not typically be regarded as suitable for LDL-lowering statin therapy; the present report suggests, therefore, that those guidelines might need to be reconsidered.

Note what those three sentences are: the first is the authors' own judgement of conclusion, not a measured value, and this article reproduces it as such rather than as data. The last two say that under the guidelines of the time it is precisely these low-risk people who would be excluded — that is, "a low risk score" is itself, in the eyes of these meta-analysts, a contestable reason for exclusion. This is the same point as the NICE section below, made by two different sources.

As for HDL — commonly called "good cholesterol", raising HDL is not the same as a proven reduction in events. All the randomised trial evidence cited in this article uses LDL lowering as the intervention; none listed here uses raising HDL as the intervention. So statements of the kind "the higher the HDL the better" go beyond the material cited here.

A contrast: what happens when it is pushed very low? Three large trials pushed LDL to different depths, and events and deaths do not point entirely the same way.

In one sentence: the direction that lowering LDL further means fewer vascular events is seen in all three trials; but all-cause mortality did not improve in step as LDL was pushed lower: the all-cause mortality difference in JUPITER reached statistical significance (hazard ratio 0.80, 95% confidence interval 0.67–0.97, P=0.02, in favour of lipid lowering), while the death counts in IMPROVE-IT were almost level and those in FOURIER slightly higher in the intervention arm, neither difference being statistically significant. That does not mean the drugs are harmful — but it does limit how far "the lower the better" can be pushed: the benefit in mortality did not accumulate as LDL went lower.

And one point of particular relevance to Hong Kong readers: among the ethnic compositions of those trials, there is no separate result for Chinese people. The CTT meta-analysis lists only one ethnic category, "White", and seven of its trials give no ethnicity data at all; JUPITER's baseline table has no "Asian" category; and FOURIER is the only trial cited here that quantifies Asian participants (2,723 of 27,564), but that figure comes from the trial registry rather than the journal paper, and it is "Asian" rather than Chinese.

#Does Hong Kong have cholesterol treatment targets of its own?

No. The reference framework series has no set for blood lipids; lipids appear only as a module appended to the hypertension reference framework, and that module states expressly that it merely lists several international guidelines for reference without adopting any of them.

The reference framework series published by the Primary Healthcare Commission covers hypertension, diabetes, preventive care for older adults, preventive care for children, preventive care for women, common musculoskeletal problems, and life-planning care. That list is complete, and there is no set for blood lipids or cholesterol in it. Where lipids appear is Module 9 — Lipid Management in Hypertensive Patients of the Hong Kong Reference Framework for Hypertension Care for Adults (Revised Edition 2021).

⚠ That module exists only in English. Although the site's Chinese page lists a download link for the "full document", that link points to the English PDF; on the Chinese page all nine professional modules, Module 9 included, point to English files. The quotations below are therefore given in the English original, with a rendering for explanation.

Module 9's position on treatment targets [Note 11]: the treatment target should be individualised for different patients; in general, the higher the cardiovascular risk, the more worthwhile it is to start lipid-lowering therapy; for patients with very high risk or high risk conditions, lipid-lowering therapy should be considered unless contraindicated; many guidelines recommend different treatment goals for patients stratified into different risk categories, and there are also guidelines recommending lipid-lowering drugs for patients considered high risk without recommending specific treatment targets; table 3 lists the treatment targets for primary prevention of some of the international guidelines, for reference.

The table's own heading likewise says that it sets out treatment target levels of lipid (if available) for primary prevention in some of the international guidelines [Note 12]. Note "some of the international guidelines" and "for reference" — from its own heading onward the table says it is illustrative, not an adopted Hong Kong standard, and it claims no exhaustiveness. Table 3 lists NCEP (2004), JBS2 (2005), JBS3 (2014), NICE (2014), ESC/EAS (2019), New Zealand (2018) and AHA/ACC (2018).

But "not adopted" and "not used" are two different things, and the difference is in the rightmost column of the same table. Table 3 has a column headed "Remarks", and in the NCEP and JBS2 rows those cells state respectively that those lipid targets are commonly used as reference in public sectors, and that those risk prediction charts are commonly used as reference in public sectors [Note 13].

That is: Hong Kong has formally adopted no international guideline as an official standard — the document's own "for reference" makes that clear; but the same document records that the public sector does in practice commonly take NCEP's targets and JBS2's prediction charts as reference. So a patient told an LDL target figure at a public clinic is not being given a Hong Kong official standard, and the figure is not out of thin air either. This article says both, because saying only one of them misleads.

The four-tier LDL target table that circulates informally — "low risk < 3.4 / moderate < 2.6 / high < 1.8 / very high < 1.4 mmol/L" — is not Hong Kong's, and is not entirely ESC/EAS's either. The ESC/EAS 2019 tiers are < 1.4 / < 1.8 / < 2.6 / < 3.0 (very high / high / moderate / low). Three of those figures come from ESC/EAS, but "low risk < 3.4" does not: 3.4 mmol/L is the Centre for Health Protection's upper end of the LDL "ideal level" for the general population, and is also ESC/EAS's non-HDL cholesterol target for moderate risk, not any of its LDL targets. The circulating table is a hybrid of two documents.

And three parts of that row are frequently cut away.

The first: the targets for the high and very high tiers are not a single absolute figure but come with a parallel condition of a reduction of at least 50% from baseline. Cut that away and the target looks a great deal easier to reach.

The second: the SCORE percentages are < 1% / 1–< 5% / 5–< 10% / ≥ 10%, and the endpoint SCORE measures is a 10-year risk of cardiovascular death, not the probability of an event in 10 years. Writing that table as "< 5% / 5–10% / 10–20% / > 20% 10-year event rates" changes both the cut-offs and the endpoint, and the result is a table that appears in no guideline at all.

The third, and the cell most easily cut from the whole table: table 3 has a column headed "Remarks". The Remarks cell of the ESC/EAS row carries a further sentence alongside the four tiers [Note 14]: for patients with established atherosclerotic cardiovascular disease who experience a second vascular event within two years (not necessarily of the same type as the first) while taking maximally tolerated statin-based therapy, an LDL-C goal below 1.0 mmol/L may be considered.

Two things about that cell. First, it sits in a table whose heading says expressly "for primary prevention", while it speaks of established patients, that is secondary prevention — the table is not internally uniform. Second, the circulating four-tier table does not have this cell, so it makes 1.4 look like the lowest tier.

Incidentally, ESC/EAS issued a focused update in 2025: the four LDL-C target values are unchanged, but risk classification is rebuilt on SCORE2 and SCORE2-OP, and the threshold for "very high risk" moves from SCORE ≥ 10% (fatal events only) to SCORE2 ≥ 20% (fatal and non-fatal events). The same category name, a doubled figure, a different endpoint. Pairing the 2019 percentages with the 2025 targets (or the reverse) likewise builds a table that does not exist.

As for the clinical situations already classified as high or very high risk without any scoring, table 1 of Module 9 has a list [Note 15]: very high risk includes established coronary artery disease, atherosclerotic cerebrovascular disease, aortic aneurysm or peripheral artery disease; diabetes mellitus with chronic kidney disease; and familial hypercholesterolaemia. High risk includes moderate to severe chronic kidney disease (eGFR < 60 ml/min/1.73 m²); and diabetes mellitus without the vascular disease or chronic kidney disease above. The same passage opens by stating that for people known to be in those two categories, estimating cardiovascular risk is unnecessary, and lipid-lowering therapy should be considered unless contraindicated.

Both lists are reproduced in full from that source. This is a list of clinical conditions, not of symptoms — whether a person falls within it is for a doctor to judge from history and examination, and it cannot be checked off against oneself.

⚠ If you have seen a "Hong Kong LDL target table" online and want to know who set it, or you have been told "your target is 1.8" and want to know where that figure comes from: Hong Kong has never published targets of its own; 1.8 is ESC/EAS's target for the high-risk group, and that row also requires a reduction of at least 50% from baseline.

#Why does Hong Kong's own document say cardiovascular risk calculators are inaccurate here?

Because modern lipid-lowering decisions rest on a cardiovascular risk score, and Hong Kong's own official document states that there is no tool designed for Chinese populations and no locally recalibrated version.

This is the single most important item in the whole material for this article. Module 9 of the Hong Kong hypertension reference framework states that there is currently no tool specifically designed for Chinese populations; that it has been suggested the Framingham equation can be applied to the Hong Kong Chinese population but requires recalibration in men because it overestimates the risk; and that there is currently no recalibrated tool available for local use [Note 16]. On the American Pooled Cohort Equations, the "Remarks" column of table 2 in the same document reads "Poor Calibration for Hong Kong Chinese", and the body text says a study has questioned its validity in Hong Kong Chinese because of poor discrimination power and calibration when applied to that population [Note 17].

Put those sentences together with the previous section and a practical situation appears: the LDL targets of the international guidelines are all decided by risk stratification (ESC/EAS by SCORE or SCORE2, the United States formerly by the Pooled Cohort Equations, the United Kingdom by QRISK3); Hong Kong has adopted no guideline's targets; Hong Kong's own document says there is no tool designed for Chinese populations, no locally recalibrated version, and that one of the main tools calibrates poorly for Hong Kong Chinese; and none of the lipid-lowering randomised trials cited here reports a separate result for Chinese people.

And another Hong Kong official document says something pointing a different way on the same question, so this article records both. The "supporting evidence" of the dyslipidaemia section of the Hong Kong Reference Framework for Preventive Care for Older Adults (Revised Edition 2021) says that for people with no history of cardiovascular disease or diabetes and no symptoms, the various cardiovascular disease assessment tools developed from the Framingham study should be used to review their total cholesterol and LDL cholesterol levels from the standpoint of overall cardiovascular risk [Note 18].

That is: Module 9 of the hypertension reference framework says the Framingham equation overestimates risk in Hong Kong Chinese men, requires recalibration, and has no locally recalibrated version; while the reference framework for older adults tells primary care staff to use Framingham-based tools to look at the lipids of people without symptoms. Both are current Hong Kong government documents. This article draws no conclusion for either side and does not average them — but the divergence is itself the evidence that "how should I read the score I calculated online" has no single answer in Hong Kong.

This does not mean lipid-lowering treatment does not work for Hong Kong people — the CTT analysis shows the effect is largely irrespective of age, sex and baseline LDL, and what a risk stratification tool affects is who should start treatment, not how the drug acts in the body. But it does explain why Hong Kong's official document uses the formulation "should be individualised for different patients" rather than setting one line for everybody. It also explains why "I calculated a score online, so my target should be X" does not hold: a score of that kind is one input to a clinical assessment, not a chart to check yourself against — and Hong Kong's own document has not even answered whether the tool applies locally.

#When should you have a lipid test, and how often?

Among the Hong Kong official documents cited here, the only one that states a screening interval for blood lipids is the Hong Kong Reference Framework for Preventive Care for Older Adults (Revised Edition 2021), and it covers only ages 50 to 75.

The summary of recommendations of that document states: screening for dyslipidaemia is recommended regularly for people aged 50 to 75; if a previous result was within the ideal range, screen every three years; if a cardiovascular risk factor is found, screen more frequently, for example every 12 months [Note 19]. Note "for example every 12 months" — that is an example, not a fixed interval.

But which are the "cardiovascular risk factors"? That is not in the summary of recommendations. Those two points go no further than "if a cardiovascular risk factor is found"; the definition is in a "#" footnote on page 42 of the same document, immediately beneath the same recommendation, and has seven items: smoking; obesity; a family history of premature cardiovascular disease in a first-degree relative; and a diagnosis of diabetes mellitus, hypertension, dyslipidaemia (higher LDL and/or lower HDL), coronary heart disease or peripheral vascular disease or ischaemic stroke, or chronic kidney disease [Note 20].

Why that footnote cannot be cut away: without it, "screen more often if you have risk factors" is something a reader cannot match against themselves, and the default answer becomes "I probably don't" — which drops them back to the sparsest interval. This is not a symptom list: several of its items (diabetes, hypertension, chronic kidney disease, known dyslipidaemia) are themselves diagnoses a doctor has to make, so the list is there to tell you what to raise with a doctor, not to tick off yourself. Nor does the document claim the list is exhaustive.

The same document carries, at the opening of the whole chronic disease screening section, a proviso about when to start: because interventions take time to take effect, in starting screening for these common chronic diseases, individual factors in an older person (frailty, comorbidity and life expectancy, for example) should be taken into account [Note 21]. In other words, an age range is a starting point, not a rule that takes effect automatically — the same set of considerations as NICE 1.5.2 below, written independently in two documents.

The other route is for patients already diagnosed with hypertension. Module 9 of the hypertension reference framework states: screening of the lipid profile should be performed for all newly diagnosed hypertensive patients, and as part of the annual assessment; that information, together with information on other risk factors, is useful in determining the individual's cardiovascular risk [Note 22]. That is: on this route a lipid test is not a standalone item, it is one input into the risk assessment. The same document also notes that for lipid management in diabetic patients, see the Hong Kong Reference Framework for Diabetes Care.

How much of that actually happens? The Population Health Survey 2020-22 measured against that recommendation: among people aged 50 to 75, 60.1% had had a cholesterol test in the past three years. So about 40% of people fall short of the government's own recommended interval.

The Centre for Health Protection has spoken about the same age band once too. The "key points" of "Cholesterol and the risk of ischaemic stroke" in Non-Communicable Diseases Watch of October 2023 say: for people at higher risk of hypercholesterolaemia (people aged 50 to 75, for example), monitoring their lipid status regularly helps them understand their own condition and so devise a disease prevention strategy [Note 23]. That sentence gives no interval ("regularly" is undefined), but it uses the same band of 50 to 75 as the reference framework for older adults.

A contrast: what about under 50? The reference framework for older adults starts at 50. None of the Hong Kong documents cited here sets a starting age or an interval for lipid screening for an ordinary person under 50 who has neither hypertension nor diabetes nor any other risk factor. That is a real gap, not something this article failed to find — the complete list of the reference framework series has no set for blood lipids, and that is established. For the other route from 45 onwards, see the section on cost below.

#Which classes of cholesterol-lowering drug are there, and how much does each lower?

Everything below is the magnitude Module 9 of the Hong Kong hypertension reference framework publishes itself. These are descriptions of pharmacological effect, not recommendations about who should take which drug — the latter is for a doctor, and this article does not go there. ⚠ Module 9 exists only in English, and the English original of each passage is at [Note 24] to [Note 28].

Statins: high intensity lowers LDL-C by 50% or more and moderate intensity by 30 to 50%; lowers triglycerides by 10 to 20%; raises HDL-C by between one per cent and 10%, so by no more than 10%. In primary and secondary prevention studies, a 25 to 55% risk reduction in cardiovascular diseases (coronary heart disease, stroke) [Note 24].

Ezetimibe: lowers LDL-C by 15 to 22% when used alone; added to an ongoing statin it lowers LDL-C by a further 21 to 27%; while in statin-naive patients, combined therapy with ezetimibe and a statin from the outset lowers LDL-C by around an additional 15% [Note 25].

Note that last part: "added to a statin already being taken" and "taken together from the outset" are two different figures (21–27% against about 15%), and the document writes them separately. Citing only the first makes the effect of combination therapy look uniformly higher. The same passage also states its place (as an add-on when the therapeutic target is not achieved at the maximum tolerated statin dose, or as an alternative for those intolerant of statins or with contraindications to them), and ends on safety: life-threatening liver failure with ezetimibe as monotherapy or in combination with statins is extremely rare; and adding ezetimibe to statin therapy does not appear to increase the incidence of elevated creatine kinase levels [Note 25].

PCSK9 inhibitors: lower LDL-C by 60% depending on dose, largely independent of any background therapy; approved as adjunctive therapy for patients with atherosclerotic cardiovascular disease or familial hypercholesterolaemia who are receiving maximally tolerated statin therapy but require additional LDL-C lowering; require subcutaneous injection; adverse events were minimal and tolerable, the most frequently reported side effects being itching at the injection site and flu-like symptoms [Note 26]. Those four points are a single group of items in the document itself, and this article reproduces all four — the last is the side effects, written in the same group as the other three, and cutting it makes a drug that has to be injected look as though no side effects had been mentioned.

Fibrates: mainly lower triglycerides by about 50%; there is no strong evidence for using fibrate therapy in primary prevention of cardiovascular disease, and their use should be considered only when statins are contraindicated [Note 27]. The same document also names a combination risk expressly: combination therapy of statin and fibrate is associated with an increased risk of abnormal transaminase levels, myositis and rhabdomyolysis; the risk is greater with higher statin doses and renal insufficiency, and the risk of rhabdomyolysis appears higher with gemfibrozil than with fenofibrate [Note 27].

And one local observation deserves separate mention. The same document states that recent studies in Hong Kong found that younger subjects (under 50), patients paying their first clinic visit and those without any comorbidities were more likely to be non-adherent or to discontinue their medications; and that these subjects should receive more meticulous monitoring of their medication-taking behaviour [Note 28].

This is one of the few observations of Hong Kong patients written into an official document: those most likely to stop are not the sickest, but the group that feels least ill. And the document does not stop at the observation — the sentence immediately after sets out what to do about it: the medication-taking behaviour of that group should be monitored more meticulously.

#Do statins really cause muscle pain? What do the randomised data say?

Muscle aching is real and extremely common — but in double-blind trials the rate in the placebo arm is almost as high as in the statin arm. To put it accurately, though: the randomised evidence does not say that statins never cause muscle pain. What CTT 2022 itself writes is that statins "caused a small excess of mostly mild muscle pain", and the relative risks it reports of 1.03 (95% confidence interval 1.01–1.06), and 1.07 (1.04–1.10) in the first year, have confidence intervals that do not cross 1 — that is, at population level the part above placebo is real, only very small. CTT's formulation is that among everyone reporting muscle pain, more than 90% of the symptoms are not caused by the drug. So the right reading is not "it is definitely not the drug" but "mostly it is not the drug, though not always" — and which side you are on is not something this article can answer; it takes a doctor judging your circumstances.

The distinction has to be made clearly, because the two are easily run together: having muscle pain is not muscle pain being caused by the drug.

CTT's 2022 meta-analysis of individual participant data from 19 double-blind placebo-controlled trials (123,940 patients) (Lancet 2022;400:832-845) reports that during a weighted mean median follow-up of 4.3 years, 16,835 participants (27.1%) allocated a statin and 16,446 (26.6%) allocated placebo reported at least one episode of muscle pain or weakness [Note 29].

The three absolute levels are far apart (27%, 16% and 5%), because the definitions and follow-up periods differ; but the structure is identical: the control arm's rate is within a fraction of a percentage point of the intervention arm's.

For the part attributable to the drug, CTT reports: an overall relative increase of 3% (RR 1.03, 95% confidence interval 1.01–1.06); a relative increase of 7% in the first year (RR 1.07, 1.04–1.10); no significant excess in first reports of muscle pain or weakness after the first year; and an absolute excess rate in the first year of 11 per 1000 person-years (95% confidence interval 6 to 16) [Note 30].

The authors' own concluding sentence is that the statin is not the cause of muscle symptoms in more than 90% of individuals who report such symptoms, and that statin therapy caused a small excess of mostly mild muscle pain [Note 31].

In other words: someone taking a statin who feels muscle aching has real pain; and on the data above there is a better than 90% chance that the pain is not caused by that drug, because people not taking it report the same symptom at almost the same rate. That is not to say "ignore it"; the same paper ends by saying that the small risks of muscle symptoms are much lower than the known cardiovascular benefits, and that there is a need to review the clinical management of muscle symptoms in patients taking a statin [Note 32].

Those two sentences are consecutive in the same conclusion, and this article reproduces both. Reproducing only the second makes a paper whose conclusion is that the risk is far below the benefit look as though it were only calling for a review.

Serious muscle damage: extremely rare, but note the time basis of the figures. Several papers use three different units, so this figure is easily misread by an order of magnitude.

In one sentence: "about one in a myriad" matches the published figures only when the time basis is five years of treatment; taken as an annual incidence it overstates by about an order of magnitude.

And beside every cell of that table the original has something not listed, which this article supplies. Rhabdomyolysis does not appear on its own in either original; it is the second half of a sentence whose first half is myopathy, milder but far commoner. CTT 2022 states that statins can, rarely, cause substantial muscle damage, that is myopathy (approximately one extra case per 10,000 person-years); or, in a more severe form, rhabdomyolysis (approximately 2 to 3 cases per 100,000 person-years) [Note 33]. The same analysis also publishes both arms for myopathy: 0.08% of those assigned any statin regimen reported myopathy against 0.04% of those assigned placebo, relative risk 1.74 (95% confidence interval 1.11–2.74) [Note 33].

CTT 2012 is the same: the "about 0.1 per 1000 over five years" of rhabdomyolysis quoted in the table above is preceded within the same sentence by myopathy, and the same passage contains two further excess risks [Note 34]: myopathy at an excess incidence of about 0.5 per 1000 over five years; an annual excess risk of haemorrhagic stroke per 1.0 mmol/L LDL reduction of the order of 0.5 per 1000 people treated over five years; and that statin therapy might be associated with a proportional increase in the diagnosis of diabetes mellitus of about 10%.

Why supply them: the table above lists only rhabdomyolysis — the rarest of the four published excess risks. A reader seeing "one in a myriad over five years" will take that for the whole of a statin's quantified risk. In the same passage the excess of myopathy is five times that, the excess of haemorrhagic stroke is of the same order as myopathy, and the diabetes item is not a "one in so many" at all but a proportional increase. The four are in different units and cannot be added.

The liver: Hong Kong publishes its own figures. Module 9 states that elevated hepatic transaminase generally occurs in 0.5% to 2% of cases and is dose dependent, with a relative risk of 2 to 4 fold at higher doses; that progression to liver failure specifically due to a statin is exceedingly rare; and that reversal of transaminase elevation is frequently noted with a reduction in dose, and elevations do not often recur with either re-challenge or selection of another statin [Note 35].

The laboratory monitoring arrangement in that Hong Kong document is: check ALT and AST before starting and within 12 weeks after starting, and repeat thereafter if clinically indicated; below 3 times the upper limit of normal, monitor carefully; at or above 3 times, stop [Note 36]. On symptoms, the same figure has two separate cells. The first is not about muscle but about general side effects and the review points: headache and dyspepsia, reviewed initially, 6 to 8 weeks after starting treatment, and at each follow-up [Note 37]. Only the second is about muscle: take blood for creatine kinase only if muscle symptoms arise; on an increase in creatine kinase, first rule out common causes such as exercise or strenuous work and advise moderation; at creatine kinase above 10 times the upper limit of normal, stop; at 3 to 10 times with symptoms, stop; and for a progressive but asymptomatic elevation, reduce the dose or discontinue temporarily [Note 38].

These are the operating rules that Hong Kong document sets out for healthcare staff. They are reproduced here so that readers know there are stated thresholds and time points behind "checking the liver" — not for readers to judge for themselves when to stop a drug. Any decision to stop or change medication is a doctor's.

That document lists two sets of contraindications, and this article reproduces both — reading only the first misses the whole category of drug interactions. Absolute contraindications: liver disease; unexplained, persistent elevations of liver enzymes; pregnant or lactating women. Relative contraindications: concomitant use of cyclosporine, gemfibrozil, niacin, macrolide antibiotics, various antifungal agents, and cytochrome P-450 inhibitors; and the document adds a note within that cell that combining a statin with the drugs listed may carry an increased risk of myositis and liver derangement [Note 39].

Note that the note is embedded in the same cell — it says why this is a list of relative contraindications. Copy the drug names without the note and the reader sees only a list, without knowing the consequence.

The same document also has a page devoted to the dose limits of one statin, which this article reproduces because it is the page in the whole document closest to a reader's daily life. That page cites the United States Food and Drug Administration's drug safety communication of 15 December 2011, whose opening states: when used with simvastatin, the following medications can raise the levels of simvastatin in the body and increase the risk of myopathy; taking no more than the recommended dose of simvastatin with these medications will help keep simvastatin levels in the body at a safer level [Note 40].

That page is particularly practical for Hong Kong readers, for two reasons. First, Module 9 is appended to the hypertension reference framework, and two of the items above — verapamil and diltiazem — and amlodipine are all antihypertensive drugs; someone taking an antihypertensive and simvastatin at the same time is exactly whom that page is written for. Second, the last line is about grapefruit juice, not a drug.

These lists are printed by the document itself, and this article has added nothing and removed nothing; but the document does not claim they exhaust every situation, so not being on a list does not mean there is certainly no problem — show a doctor or pharmacist everything you take and drink. The dose limits above are written for prescribers, not for readers to adjust their own doses by.

#How much do diet and exercise actually do?

Hong Kong has two official documents giving upper limits for fat intake, and their saturated fat limits do not agree — worth knowing, because both figures come from the government itself.

The Centre for Health Protection's Cholesterol leaflet (revised 2025), on a 2000 kcal diet, publishes daily upper limits for fat intake of: total fat 60 grams, saturated fat 20 grams, trans fat 2.2 grams.

Module 9 of the Hong Kong hypertension reference framework sets lifestyle targets for dyslipidaemia as: reduction of dietary fat intake; total fat less than 30% of total calories a day; saturated fat less than 7%, cholesterol less than 200 mg; and avoid any trans fat [Note 41].

The passage before those four items raises something prior, which this article reproduces too: in case of any secondary causes of dyslipidaemia such as hypothyroidism, diabetes, liver disease, nephrotic syndrome or steroid treatment, they should be identified and treated accordingly [Note 42].

That is: before the question "how much do diet and exercise do", the document asks a different question first — whether the raised lipids are caused by something else. That is not something a reader can test for themselves; it is for a doctor to work through. But knowing that layer exists is what makes it clear why an abnormal report does not necessarily mean "change your diet" straight away.

Do the arithmetic once (putting the two documents on the same calorie basis): fat carries about 9 kcal a gram; 20 grams of saturated fat times 9 is 180 kcal; 180 divided by 2000 is 9% of total calories. And Module 9's limit is "less than 7%". That is: on the same 2000 kcal basis, the two Hong Kong official documents differ by about two percentage points of calories in their saturated fat limit (the Centre for Health Protection about 9%, the reference framework under 7%). Both figures are published, and this article neither chooses between them nor averages them.

Note that the Centre for Health Protection's figures are printed in the same cell as, and immediately alongside, a prompt: for dietary advice for individuals with high blood lipids or chronic disease, ask a healthcare professional. That is: the 60, 20 and 2.2 are general advice on a basis of 2,000 kcal for an ordinary adult, and the leaflet says itself that anyone already with high lipids or a chronic illness should ask a healthcare professional about dietary advice separately. The two percentage points between the two documents are not a question for a reader to take sides on.

As for dietary cholesterol itself, the Centre for Health Protection's original wording is quoted above: there is at present insufficient evidence on which to make a recommendation limiting intake, but several medical organisations recommend that intake be as low as possible. Note that Module 9 writes "cholesterol <200 mg" on the same item — so on this one the two documents also take different positions.

How much do exercise and weight loss lower LDL? The Hong Kong material cited here publishes no percentage by which lifestyle intervention lowers LDL. Commonly seen figures such as "cutting saturated fat lowers LDL by 5%–10%", "more soluble fibre lowers it by 5%–10%" and "losing 5%–10% of weight lowers LDL by 5%–10%" have no counterpart in the Hong Kong documents cited here, and are therefore not stated.

#Several major foreign guidelines are in fact each saying different things

An LDL target is not an international consensus — three big systems use three completely different approaches, and Hong Kong has formally adopted none of them.

Note the "70 mg/dL" in the AHA/ACC row: the original (Top 10 Take-Home Messages, point 3) confines that value expressly to "very high-risk ASCVD" — patients with established atherosclerotic cardiovascular disease at very high risk — so it is a secondary prevention rule, not a primary prevention target. AHA/ACC 2018 never uses that threshold anywhere in primary prevention, where the basis remains what the table says: percentage reduction, with no LDL target value. The subject of this table is a comparison of the four guidelines' primary prevention bases, and the "70 mg/dL" is set out here purely to record that such a rule exists within that guideline; it cannot be compared directly with the primary prevention target values in the ESC/EAS row.

Note the "a single risk threshold decides prescribing" in the NICE row: that describes only how NG238's prescribing threshold (1.6.7) itself is decided, and does not mean the threshold has no exceptions. The two recommendations immediately after it — 1.6.8 and 1.6.9 — are not doors closing but doors opening.

Both USPSTF and NICE use "a ten-year cardiovascular risk above some threshold" to decide whether to start a statin. This article does not reproduce those two threshold rules, for the following reasons.

⚠ This article does not reproduce the prescribing threshold values in the USPSTF recommendation statement or in NICE NG238, nor the corresponding drugs and doses. Both documents are directed at clinicians: the subject of the USPSTF sentence is "clinicians prescribe", and the NICE recommendation sits after a whole clinical assessment pathway in NG238 and does not stand alone. The input to both rules is a ten-year risk score — and that is precisely the kind of tool Hong Kong's own official document says has no version designed for Chinese populations and no locally recalibrated version. A reader who calculates a figure online and checks it against a threshold arrives at "I do not need medication" or "I should take drug X at dose Y"; neither conclusion is one those documents were written to let a reader draw, and the first is a self-exclusion. The rules exist, can be consulted, and are used by doctors; this article reports only what they are based on, not the threshold values and doses. But not reproducing the threshold does not mean leaving out what stands beside it — the two NICE recommendations that follow it, pointing the opposite way, are reproduced below.

NG238 puts the prescribing threshold at 1.6.7; 1.6.8 and 1.6.9, which follow, are not exclusion rules but two provisions that open doors. What distinguishes them from the threshold value is that they cannot lead any reader to exclude themselves.

The verb of 1.6.8 is a prohibition: "Do not rule out treatment". The reason prohibited is, in the original, "just because the person's 10-year QRISK3 score is less than" a threshold value (which this article does not reproduce). And it names expressly two situations in which treatment should not be ruled out even where the score is below the threshold: where the person has an informed preference for taking a statin, or where there is concern that risk may be underestimated [Note 43].

1.6.9 is the age one, and likewise not an exclusion rule: treatment may be considered for people aged 85 and older (the drug and dose that follow are not reproduced here), with an immediate reminder to be aware of factors that may make treatment inappropriate, referring to recommendations 1.5.1 and 1.5.2 [Note 44].

And the two that 1.6.9 points to contain no values at all and can be reproduced in full [Note 45]: decisions about starting statin treatment should be made after an informed discussion between the clinician and the person about the risks and benefits of statins; and account should be taken of potential benefits from lifestyle changes, the person's preferences, the presence of any comorbidities, whether they are on multiple medications, whether they are frail, and their life expectancy.

In one sentence: a score is not an answer. In NICE's own document, the two recommendations immediately after the threshold are one saying not to rule out on a low score and one saying treatment may be considered at 85 and above — both open doors rather than closing them; and what both point to is the "informed discussion between the clinician and the person" of 1.5.1. So "I calculated a score online and it is below the threshold" has never been a conclusion within the document that contains the rule.

NICE's primary prevention target (as distinct from the prescribing threshold) is a percentage reduction: for primary prevention of cardiovascular disease, aim for a greater than 40% reduction in non-HDL cholesterol [Note 46].

Three points most easily got wrong, worth setting out on their own.

One, units. The American guidelines use mg/dL, and Hong Kong and Europe use mmol/L. 70 mg/dL is 1.8 mmol/L; 100 mg/dL is 2.6 mmol/L.

Two, the same figure with two meanings. "1.8 mmol/L" in AHA/ACC 2018 is the trigger for considering the addition of non-statin drugs in secondary prevention for very high-risk ASCVD patients, and in ESC/EAS it is the target value for the high-risk group in primary prevention. The same figure, different guidelines, different roles, and not even the same level of prevention.

Three, a different analyte. In primary prevention NICE uses non-HDL cholesterol, not LDL; and ESC/EAS states itself that non-HDL-C targets are 0.8 mmol/L higher than the corresponding LDL-C targets. The two are not interchangeable. Note that this distinction holds only for primary prevention: NG238 has a separate secondary prevention recommendation (1.7.1) that sets absolute values for LDL cholesterol and non-HDL cholesterol side by side as equivalent alternatives. So "NICE does not use LDL" holds only in primary prevention.

In one sentence: when a Hong Kong reader sees three different "target" figures, it is usually not that someone has it wrong, but that the three come from three different systems, and Hong Kong has formally adopted none of them.

#What does managing blood lipids actually cost in Hong Kong?

In the public system, standard statins and ezetimibe are both "General Drugs" on the Hospital Authority Drug Formulary, dispensed at the standard charge — 5 dollars per drug per four-week unit at a family medicine clinic.

The Drug Formulary's definition of the category is: general drugs are drugs with proven efficacy and safety for the patients' relevant clinical conditions and available for general use, and public hospitals and clinics charge a standard fee when providing them [Note 47]. In the Hospital Authority Drug Formulary (search results of 2 August 2026), simvastatin, atorvastatin, rosuvastatin and ezetimibe are all listed under "General Drugs". That result covers only those four drugs, not the whole formulary.

Hospital Authority charges from 1 January 2026: 150 dollars per family medicine clinic attendance and 5 dollars per drug; 250 dollars per specialist outpatient attendance and 20 dollars per drug; and an annual out-of-pocket cap of 10,000 dollars per calendar year, with no means test (the cap excludes self-financed items and appliances). One drug item is one four-week supply unit.

Do the arithmetic once (working out a year's drug cost from the charges above): 52 weeks a year divided by 4 weeks is 13 drug item units. At a family medicine clinic, 13 times 5 dollars is 65 dollars a year (for the drug cost of one lipid-lowering drug alone, excluding the consultation fee); at a specialist outpatient clinic, 13 times 20 dollars is 260 dollars a year. Neither figure includes consultation fees or laboratory costs, and the number of attendances depends on what the doctor arranges.

Another route: the Chronic Disease Co-Care Pilot Scheme. The scheme's frequently asked questions state that for screening of cardiovascular risk factors (hypertension, hyperglycaemia and dyslipidaemia), the family doctor charges a participant a one-off co-payment of 120 dollars or less at their first subsidised consultation in the screening stage, covering all consultations, laboratory tests, diagnosis and the drawing up of a management plan in the screening stage; and that after the scheme extended its scope to lipid testing, the co-payment participants pay is unchanged [Note 48].

Eligibility is: people aged 45 or above who have not been diagnosed with diabetes or hypertension may enrol at a District Health Centre or Station, or at the clinic of a family doctor who has joined the scheme and offers enrolment [Note 49]. On the number of subsidised consultations in the treatment stage, the scheme's introduction page states: only where dyslipidaemia reaches a specified level, up to 4 subsidised consultations in the first "personal scheme year", and up to 2 a year from the second "personal scheme year" [Note 50]. And on drug costs: the cost of these drugs is included in the co-payment for a subsidised consultation in the treatment stage, so that even where several drugs are prescribed at once, no additional drug charge is payable [Note 51]. The government's recommended treatment-stage consultation co-payment is "currently 150 dollars", with the actual amount set by each family doctor.

The point of this section: the most immediate worry about "having to take a drug for life" is money. In the public system the drug cost of a standard lipid-lowering drug is 5 dollars an item per four weeks; in the treatment stage of the Co-Care scheme, the cost of drugs on the specified list is included in the co-payment. The cost pressure is not on standard statins — it is on combination products, second-line drugs, and self-financed items.

⚠ This article makes no statement about the formulary category or cost of PCSK9 inhibitors. The search results above did not cover that class (evolocumab, alirocumab), so this article will not say whether they are general drugs, special drugs or self-financed items, and will not say whether they are dear or otherwise.

#What to do next

1. First be clear what basis the figure in your hand has. Total cholesterol 5.2 is the upper end of an ideal level and a statistical cut-off, not a treatment threshold; LDL 3.4 is an ideal level for the general population, not a target for any risk tier.
2. Do not exclude yourself on the score from an online calculator. Hong Kong's own document says there is no tool designed for Chinese populations and no locally recalibrated version; and the guideline that sets a threshold follows it immediately with "Do not rule out treatment".
3. Ages 50 to 75: every three years if the last result was ideal. More often if you have a cardiovascular risk factor, the document's example being every 12 months. Those seven risk factors are set out in the body — the list is there to tell you what to raise with a doctor, not to tick off yourself.
4. If you have been diagnosed with hypertension, a lipid test is part of the annual assessment. It is not an extra item; it is one input into the risk assessment.
5. Aged 45 or above and not diagnosed with diabetes or hypertension: look once at the Chronic Disease Co-Care Pilot Scheme. The one-off screening-stage co-payment of 120 dollars or less already covers all consultations, laboratory tests, diagnosis and the management plan in that stage.
6. Do not stay away because you are worried about drug costs. In the public system all four commonly used lipid-lowering drugs are listed as general drugs, at 5 dollars per drug per four weeks at a family medicine clinic; and there is an annual out-of-pocket cap of ten thousand dollars with no means test.
7. If you take a statin and have muscle aching, treat it as something to raise with a doctor, not a reason to stop on your own. The document says creatine kinase is checked only when muscle symptoms arise, and the thresholds for stopping (creatine kinase above 10 times the upper limit of normal, or 3 to 10 times with symptoms) are written for prescribers.
8. Show a doctor or pharmacist everything you take, medicines and supplements together, once. The contraindication list on that simvastatin page contains three antihypertensive drugs, and its last item is grapefruit juice.
9. Under 50, without hypertension or diabetes and without other risk factors: Hong Kong has never set a starting age or interval. That is a real gap, not something this article failed to find; if you have a question, talk to your doctor.

#Frequently asked questions

Total cholesterol 5.3 — does that mean I have a disease?

5.2 mmol/L is the upper end of the "ideal level" listed in the Centre for Health Protection's Cholesterol leaflet, and also the cut-off the Population Health Survey uses to count prevalence. None of the Hong Kong documents cited here sets 5.2 as a threshold for starting treatment; Module 9 of the hypertension reference framework takes the position that treatment targets "should be individualised for different patients". What it means in practice is for a doctor to judge on the whole picture.

Is Hong Kong's LDL target 1.8?

Hong Kong has never published an LDL target of its own. 1.8 mmol/L is ESC/EAS 2019's target for the high-risk group, reproduced in table 3 of the Hong Kong hypertension reference framework as one of "some of the international guidelines … for reference". And that row's original wording also requires a reduction of at least 50% from baseline ("≥ 50% reduction on LDL-C"), the two conditions in parallel. One more sentence is needed: the "Remarks" column at the right of the same table records that NCEP's targets and JBS2's prediction charts are "commonly used as reference in public sectors" — "not formally adopted" and "not used as a reference by anyone" are two different things.

Do statins cause muscle pain?

Muscle aching is extremely common in both arms of double-blind trials: CTT 2022 gives 27.1% in the statin arm against 26.6% on placebo; JUPITER 16.0% against 15.4%; FOURIER 5.0% against 4.8%. CTT's conclusion in the original is that "the statin is not the cause of muscle symptoms in more than 90% of individuals who report such symptoms" — that is, more than 90% of the symptoms reported are not caused by the statin. The symptoms are real. But the same paper also states that statins "caused a small excess of mostly mild muscle pain", with relative risks of 1.03 (1.01–1.06) and 1.07 (1.04–1.10) in the first year, neither confidence interval crossing 1 — so the correct statement is: most reported muscle pain is not caused by the drug, but the small part above placebo is real. The paper's concluding passage puts first that "The small risks of muscle symptoms are much lower than the known cardiovascular benefits", and only then notes the need to review the clinical management of such symptoms.

After one lipid test, how long before the next?

The Hong Kong Reference Framework for Preventive Care for Older Adults (Revised Edition 2021) recommends, for people aged 50 to 75: every three years if a previous result was within the ideal range; and more frequently if a cardiovascular risk factor is found, the document's example being every 12 months. For patients already diagnosed with hypertension, Module 9 of the hypertension reference framework provides that a lipid test should be part of the annual assessment.

Are online cardiovascular risk calculators accurate?

Module 9 of the Hong Kong hypertension reference framework states "There is currently no tool specifically designed for Chinese populations" and "There is currently no recalibrated tool available for local use", and notes of the American Pooled Cohort Equations "Poor Calibration for Hong Kong Chinese".

My score online is below the threshold — does that mean I need not bother?

That conclusion is not one the rule itself draws. After the prescribing threshold, NICE NG238's next recommendation has a prohibition for its verb: "Do not rule out treatment" — the original states that treatment must not be ruled out merely because a ten-year risk score is below a threshold (a value this article does not reproduce), and names two situations: where the person has an informed preference for taking a statin, or where there is concern that risk may be underestimated. The recommendation after that is the age one: treatment may be considered at 85 and above (the drug and dose that follow are not reproduced here). Both point to the same document's 1.5.1 and its "informed discussion between the clinician and the person". On the other side, the authors of CTT 2012, having published the absolute benefit in the low-risk group, also wrote that under the guidelines of the time such people would not typically be regarded as suitable for treatment, and that those guidelines might therefore need to be reconsidered. Neither source is telling anyone to take a drug; both are saying that "a low score" is not itself a conclusion.

Is lower LDL always better?

On vascular events, all three trials cited here show a reduction (JUPITER HR 0.56; IMPROVE-IT HR 0.936, 95% confidence interval 0.89–0.99; FOURIER HR 0.85, 95% confidence interval 0.79–0.92). On all-cause mortality the three do not agree: the all-cause mortality difference in JUPITER reached statistical significance (HR 0.80, 95% confidence interval 0.67–0.97, P=0.02) in favour of the statin; but IMPROVE-IT gave 1,215 against 1,231 (HR 0.99, 95% confidence interval 0.91–1.07) and FOURIER 444 (3.2%) against 426 (3.1%) (HR 1.04, 95% confidence interval 0.91–1.19), neither difference being statistically significant. So "the lower the better" has support at the level of events; at the level of mortality, starting a statin has data behind it, but "pushing LDL still lower on top of a statin" shows no matching gain in mortality.

#Notes: the official texts

[Note 1] Hong Kong Reference Framework for Hypertension Care for Adults [patient version] (revised July 2022), Department of Health:

Blood lipids are made up mainly of triglycerides and cholesterol. Dyslipidaemia means an abnormal concentration of triglycerides or lipoproteins in the blood, and is a major risk factor for cardiovascular disease. (our translation from the Chinese original)

Chinese original:

「血脂主要是由三酸甘油脂及膽固醇組成。血脂異常是指血液中三酸甘油脂或血脂蛋白濃度異常，是引致心血管疾病的主要風險因素」

[Note 2] Centre for Health Protection, Cholesterol leaflet (revised 2025):

Although there is at present insufficient evidence on which to make a recommendation limiting the intake of dietary cholesterol, several medical organisations recommend that the intake of dietary cholesterol be as low as possible. For healthy people, foods high in cholesterol but lower in fat such as eggs, squid, prawns and crabs should be counted within the intake of "meat, fish, eggs and alternatives" and eaten in moderation. For dietary advice for individuals with high blood lipids or chronic disease, please ask a healthcare professional. (our translation from the Chinese original)

Chinese original:

「雖然現時未有足夠證據就膳食膽固醇的攝取限制作出建議，但多個醫學組織建議，膳食膽固醇的攝入量應是越少越好。」 「對於健康人士，雞蛋、魷魚、蝦、蟹等含高膽固醇但脂肪含量較低的食物，應作「肉、魚、蛋及代替品」攝入量計算及適量食用。」 「有關個別高血脂或長期疾病患者的飲食建議，請向醫護人員查詢。」

The same leaflet's introduction:

The levels of the various kinds of cholesterol can be learnt from a blood test, helping us to assess the risk of coronary heart disease. The following are the ideal cholesterol levels derived from statistics, for reference: (our translation from the Chinese original)

Chinese original:

「各類膽固醇的水平可由驗血得知，以助我們評估患上冠心病的風險。以下是根據統計所得的膽固醇理想水平，以供參考：」

[Note 3] The same leaflet:

Saturated fat makes the blood clot more readily, leading to hardening of the arteries, stroke, heart disease and the like, and promotes the liver's production of cholesterol, raising the level of bad cholesterol in the blood — an ill effect greater than that of excessive dietary cholesterol intake! (our translation from the Chinese original)

Chinese original:

「飽和脂肪使血液更易凝結，引致血管硬化、中風、心臟病等疾病，並促進肝臟產生膽固醇，令血液的壞膽固醇水平上升，其不良影響比過量攝取膳食膽固醇還大！」

[Note 4] Department of Health, Report of the Population Health Survey for the three years to 2022 (Part II, 2023), summary:

Among people aged 15 to 84, the prevalence of raised blood cholesterol or hypercholesterolaemia was 51.9% (women 51.0%, men 52.9%), comprising 15.7% who self-reported having been diagnosed by a doctor with raised blood cholesterol, and 36.2% with no self-reported history whose laboratory test found raised total cholesterol (defined as total cholesterol at or above 5.2 mmol/L). By age group, the prevalence of raised blood cholesterol or hypercholesterolaemia was highest at ages 55 to 64 (women 76.6%, men 67.0%). (our translation from the Chinese original)

Chinese original:

「在15－84歲人士中，血膽固醇過高或高膽固醇血症的患病率為 51.9%（女性為 51.0%，男性為52.9%），包括 15.7%自述經醫生診斷患有血膽固醇過高，及 36.2%沒有自述病史但在化驗檢測中驗出總膽固醇偏高（定義為總膽固醇高於或等於 5.2 mmol/L）。按年齡組別分析，55－64歲人士的血膽固醇過高或高膽固醇血症患病率最高（女性為 76.6%，男性為 67.0%）。」

[Note 5] The same report, §3.2.2:

In this survey, a participant whose measured total cholesterol in the laboratory test was 5.2 mmol/L or above was defined as having hypercholesterolaemia. (our translation from the Chinese original)

Chinese original:

「在本調查中，如果參與者在化驗檢測中被量度的總膽固醇為 5.2mmol/L或以上，就會被定義為高膽固醇血症。」

[Note 6] Yan BPY and others, Hong Kong Med J 2024;30:90–3:

According to the Hong Kong Population Health Survey conducted between 2020 and 2022, the prevalence of high blood cholesterol among individuals aged 15 to 84 years in the Hong Kong general population increased from 8.4% in 2003/2004 to 51.9% in 2022.

[Note 7] Population Health Survey 2003/04, English executive summary:

About one in twelve (8.4%) reported that they had been diagnosed of having high blood cholesterol by a doctor.

[Note 8] CTT, Lancet 2012;380:581-90:

This meta-analysis included individual participant data from 22 trials of statin versus control (n=134,537; mean LDL cholesterol difference 1·08 mmol/L; median follow-up 4·8 years)

Reduction of LDL cholesterol with a statin reduced the risk of major vascular events (RR 0·79, 95% CI 0·77-0·81, per 1·0 mmol/L reduction), largely irrespective of age, sex, baseline LDL cholesterol or previous vascular disease

[Note 9] The same paper:

In individuals with 5-year risk of major vascular events lower than 10%, each 1 mmol/L reduction in LDL cholesterol produced an absolute reduction in major vascular events of about 11 per 1000 over 5 years.

[Note 10] The same paper, immediately following:

This benefit greatly exceeds any known hazards of statin therapy. Under present guidelines, such individuals would not typically be regarded as suitable for LDL-lowering statin therapy. The present report suggests, therefore, that these guidelines might need to be reconsidered.

[Note 11] Module 9 of the Hong Kong hypertension reference framework (English only):

The treatment target should be individualised for different patients. In general, the higher the cardiovascular risk, the more worthwhile to start lipid lowering therapy. For patients who have very high risk or high risk conditions (Table 1), lipid lowering therapy should be considered unless contraindicated. Many of the guidelines recommend different treatment goals for patients who have been stratified under different risk categories. There are also guidelines recommending the use of lipid lowering drugs for patients considered as high risk and do not recommend specific treatment targets. The treatment targets (if available) for primary prevention of some of the international guidelines are listed for reference in table 3.

[Note 12] The same document, the heading of table 3:

Table 3. Treatment target levels of lipid (if available) for primary prevention in some of the international guidelines

[Note 13] The same document, the Remarks column of table 3:

Lipid targets are commonly used as reference in public sectors

(the NCEP row);

Prediction charts are commonly used as reference in public sectors

(the JBS2 row).

[Note 14] The same document, the Remarks column of the ESC/EAS row:

For patients with ASCVD who experience a second vascular event within 2 years (not necessarily of the same type as the first event) while taking maximally tolerated statin-based therapy, an LDL-C goal of <1.0 mmol/L (<40 mg/dL) may be considered.

[Note 15] The same document, table 1:

It has to emphasise that estimation of the cardiovascular risk is not necessary for individuals with known very high or high risk conditions (Table 1). Lipid lowering therapy should be considered for these individual unless contraindicated.

Very high risk:

(1) Individuals with established coronary artery disease, atherosclerotic cerebrovascular disease, aortic aneurysm or peripheral artery disease (2) Individuals with diabetes mellitus with chronic kidney disease (3) Individuals with familial hypercholesterolaemia

High risk:

(1) Individuals with moderate to severe chronic kidney disease (estimated glomerular filtration rate [eGFR] <60ml/min/1.73 m2) (2) Individuals with diabetes mellitus without established coronary artery disease, atherosclerotic cerebrovascular disease, aortic aneurysm, peripheral artery disease or chronic kidney disease

[Note 16] The same document:

There is currently no tool specifically designed for Chinese populations.

It had been suggested that Framingham equation can be applied to the Hong Kong Chinese population but requires recalibration in men due to overestimation of the risk10. There is currently no recalibrated tool available for local use

[Note 17] The same document, the Remarks column of table 2: "Poor Calibration for Hong Kong Chinese10"; and the body text:

Study had questioned its validity in Hong Kong Chinese due to poor discrimination power and calibration when applied to the Chinese population in Hong Kong10

[Note 18] Hong Kong Reference Framework for Preventive Care for Older Adults (Revised Edition 2021), the "supporting evidence" of the dyslipidaemia section:

As for people with no history of cardiovascular disease or diabetes and no symptoms, the various cardiovascular disease assessment tools developed from the Framingham study should be used to review their total cholesterol and low-density lipoprotein cholesterol levels from the standpoint of overall cardiovascular risk. (our translation from the Chinese original)

Chinese original:

「至於沒有心血管疾病或糖尿病病歷、也沒有病徵的人，應使用各種根據弗雷明漢研究制定的心血管疾病評估工具，從整體心血管疾病風險的角度檢視他們的總膽固醇和低密度脂蛋白膽固醇的水平。」

[Note 19] The same document, summary of recommendations:

Dyslipidaemia ▪ Screening for dyslipidaemia is recommended regularly for people aged 50 to 75. (page 41) ▪ Screen for dyslipidaemia every three years if a previous result was within the ideal range; if a cardiovascular disease risk factor is found, screen more frequently, for example every 12 months. (page 42) (our translation from the Chinese original)

Chinese original:

「高血脂 ▪ 建議50 至75 歲的人士定期接受高血脂篩檢。(第41 頁) ▪ 如先前的結果在理想範圍內，每三年接受高血脂篩檢一次；如發現心血管疾病風險因素，應更頻密地接受篩檢，例如每12 個月一次。(第42 頁)」

[Note 20] The same document, the "#" footnote on page 42 of the main text:

Any one of the following increases the risk of cardiovascular disease: ▪ smoking ▪ obesity ▪ a family history of premature cardiovascular disease in a first-degree relative ▪ patients diagnosed with any of the following: − diabetes mellitus − hypertension − dyslipidaemia, with a higher low-density lipoprotein cholesterol level and/or a lower high-density lipoprotein cholesterol level − coronary heart disease, peripheral vascular disease or ischaemic stroke − chronic kidney disease (our translation from the Chinese original)

Chinese original:

「如有下列任何一項，會增加患心血管疾病的風險： ▪ 吸煙 ▪ 肥胖 ▪ 直系親屬患有早發性心血管疾病的家族病歷 ▪ 被診斷患有下列疾病的病人： － 糖尿病 － 高血壓 － 高血脂，低密度脂蛋白膽固醇水平較高及／或高密度脂蛋白膽固醇水平較低 － 冠心病、周邊血管疾病或缺血性中風 － 慢性腎病」

[Note 21] The same document:

On the other hand, because interventions take time to take effect, individual factors in an older person (frailty, comorbidity and life expectancy, for example) should be taken into account in starting screening for these common chronic diseases. (our translation from the Chinese original)

Chinese original:

「另一方面，由於介入措施發揮效用需時，開始篩檢這些常見的慢性病時，應顧及長者的個別因素(例如體弱多病、並存病和預期壽命)」

[Note 22] Module 9 of the Hong Kong hypertension reference framework:

Screening of lipid profile should be performed for all newly diagnosed hypertensive patients, and as a part of the annual assessment1. This information, together with information on other risk factors, is useful in determining the individual's cardiovascular risk and provides insight into the subsequent management.

[Note 23] Non-Communicable Diseases Watch, October 2023, "Cholesterol and the risk of ischaemic stroke", key points:

For people at higher risk of hypercholesterolaemia (people aged 50 to 75, for example), monitoring their lipid status regularly helps them understand their own condition and so devise a disease prevention strategy (such as a change of lifestyle). Members of the public may consult a doctor about testing for dyslipidaemia. (our translation from the Chinese original)

Chinese original:

「對於高膽固醇血症風險較高的人士（如 50 至 75 歲的人士），定期監測血脂狀況有助他們了解自己的身體狀況，從而制訂疾病預防策略（如改變生活方式）。市民可以向醫生諮詢有關高血脂檢測。」

The same issue also carries:

More importantly, as many as 70% of people with raised cholesterol levels or hypercholesterolaemia were unaware of their condition, and learnt of it only through the blood test provided by taking part in the survey (our translation from the Chinese original)

Chinese original:

「更重要的是，高達70%的膽固醇水平升高或高膽固醇血症患者並未知悉自己的情況，而是經參與調查所提供的血液化驗檢測後才獲悉」

[Note 24] Module 9, statins:

↓ LDL-C ≥50%, if high intensity and 30-50% if moderate intensity, ↓TG 10-20%, ↑ HDL-C 1-10%12 / 25-55% risk reduction in cardiovascular diseases (coronary heart disease, stroke) in primary and secondary prevention studies

[Note 25] The same document, ezetimibe:

↓TG 8%, ↑HDL-C 3%, ↓LDL-C 15-22% if using ezetimibe alone. Adding ezetimibe to an ongoing statin reduces LDL-C levels by an additional 21-27%. In statin naive patients, combined therapy with ezetimibe and statin reduces LDL-C levels by around an additional 15%.

Can be used as an add-on drug in association with statins when the therapeutic target is not achieved at the maximum tolerated statin dose, or as an alternative to statins in patients who are intolerant of statins or with contraindications to statins4,12

Life-threatening liver failure with ezetimibe as monotherapy or in combination with statins is extremely rare. The addition of ezetimibe to statin therapy does not appear to increase the incidence of elevated CK levels.

[Note 26] The same document, PCSK9 inhibitors:

↓TG 26%, ↑HDL-C 9%,↓ LDL-C 60%, depending on dose, largely independent of any background therapy12 / Have been approved as adjunctive therapy for patients with atherosclerotic cardiovascular disease (ASCVD) or familial hypercholesterolaemia who are receiving maximally tolerated statin therapy but require additional lowering of LDL-C28. / Requires subcutaneous injection / Adverse events were minimal and tolerable29. Among the most frequently reported side effects are itching at the site of injection and flu-like symptoms12.

[Note 27] The same document, fibrates:

↓ TG 50%, ↑ HDL-C ≤20%, ↓ LDL-C ≤20%12 / There is no strong evidence for using fibrate therapy in primary prevention of cardiovascular disease12,28. The use of fibrates in these patients should only be considered when statins are contraindicated.

Combination therapy of statin and fibrate is associated with an increased risk for abnormal transaminase levels, myositis, and rhabdomyolysis. The risk of rhabdomyolysis is more common with higher doses of statins and renal insufficiency and appears to be higher when statins are combined with gemfibrozil (compared with fenofibrate)19,28. Hence, gemfibrozil should not be initiated in patients on statin therapy and fenofibrate is the preferred agent when used in combination with statin but should be used with cautions and under close monitoring.

[Note 28] The same document:

Recent studies performed in Hong Kong found that younger subjects (<50 years), patients who paid their first clinic visit and those without any comorbidities were more likely non-adherent or discontinuing their medications23,24. These subjects should receive more meticulous monitoring of their medication-taking behaviour.

[Note 29] CTT, Lancet 2022;400:832-845:

16 835 (27·1%) participants assigned a statin versus 16 446 (26·6%) participants assigned placebo reported at least one episode of muscle pain or weakness during a median of 4·3 years.

[Note 30] The same paper:

This corresponded to a 3% relative increase (RR 1·03; 95% CI 1·01–1·06

Statin therapy produced a 7% relative increase in muscle pain or weakness during the first year (RR 1·07; 95% CI 1·04–1·10)

After year 1, there was no significant excess in first reports of muscle pain or weakness (0·99; 0·96–1·02).

allocation to a statin regimen resulted in an absolute excess rate of muscle pain or weakness of 11 (95% CI 6 to 16) per 1000 person-years in the first year

[Note 31] The same paper:

the statin is not the cause of muscle symptoms in more than 90% of individuals who report such symptoms

Statin therapy caused a small excess of mostly mild muscle pain. Most (>90%) of all reports of muscle symptoms by participants allocated statin therapy were not due to the statin.

[Note 32] The same paper:

The small risks of muscle symptoms are much lower than the known cardiovascular benefits. There is a need to review the clinical management of muscle symptoms in patients taking a statin.

[Note 33] The same paper:

It is known that statins can, rarely, cause substantial muscle damage (ie, myopathy [approximately one extra case per 10 000 person-years]; or, in a more severe form, rhabdomyolysis [approximately 2–3 cases per 100 000 person-years]).

Myopathy (based on Medical Dictionary for Regulatory Activities coding) was reported by 0·08% of those assigned any statin regimen versus 0·04% of those assigned placebo (RR 1·74; 95% CI 1·11–2·74)

[Note 34] CTT, Lancet 2012:

statin therapy is associated with a small increased risk of myopathy (excess incidence of about 0·5 per 1000 over 5 years) and, more rarely, of rhabdomyolysis (excess incidence of about 0·1 per 1000 over 5 years).

the annual excess risk of haemorrhagic strokes per 1·0 mmol/L LDL cholesterol reduction might be of the order of 0·5 per 1000 people treated over 5 years.

statin therapy might be associated with a proportional increase in the diagnosis of diabetes mellitus of about 10%

[Note 35] Module 9:

Elevated hepatic transaminase generally occurs in 0.5%-2% of cases and is dose dependent41, 42, with relative risk 2 – 4 fold at higher doses of statin

Progression to liver failure specifically due to statin is exceedingly rare if ever occurs43

Reversal of transaminase elevation is frequently noted with a reduction in dose, and elevations do not often recur with either re-challenge or selection of another statin44, 45

[Note 36] The same document:

Monitoring-Laboratory ALT/AST12,30 • Before start • Within 12 weeks after start of statin • Thereafter repeat if clinically indicated • <3 x ULN → careful monitoring • >/=3 x ULN → STOP

[Note 37] The same document:

Monitoring-Symptoms Headache and Dyspepsia30: • Initial • 6-8 weeks after therapy • Each follow up

[Note 38] The same document:

Muscle Soreness/Tenderness/Pain30: • Blood for CK only if muscle symptoms arise • Increase in CK → Rule out common causes like Exercise / Strenuous work → Advise Moderation • CK> 10x ULN → STOP • CK 3-10x ULN + symptoms → STOP • Progressive but asymptomatic CK elevation → Reduction in dose or temporary discontinuation29

[Note 39] The same document, absolute contraindications:

Liver disease/ unexplained, persistent elevations of liver enzymes/ pregnant or lactating women

Relative contraindications:

Concomitant use of cyclosporine, gemfibrozil, niacin, macrolide antibiotics, various antifungal agents, and cytochrome P-450 inhibitors (Note: Combination of statin with drugs listed may carry an increase in risk of myositis and liver derangement.)

[Note 40] The same document, the opening of the "Simvastatin dose limitations" page:

When used with simvastatin, the following medications can raise the levels of simvastatin in the body and increase the risk of myopathy. Taking no more than the recommended dose of simvastatin with these medications will help keep simvastatin levels in the body at a safer level.

[Note 41] The same document, lifestyle targets:

Reduction of dietary fat intake / Total fat <30% of total calorie/day / Saturated fat <7%, cholesterol <200 mg / Avoid any trans fat

[Note 42] The same document, immediately before:

In case of any secondary causes of dyslipidaemia such as hypothyroidism, diabetes, liver disease, nephrotic syndrome or steroid treatment, they should be identified and treated accordingly.

[Note 43] NICE NG238, recommendation 1.6.8: "Do not rule out treatment", the reason prohibited being in the original "just because the person's 10-year QRISK3 score is less than" a threshold value (which this article does not reproduce), and naming "if they have an informed preference for taking a statin or there is concern that risk may be underestimated".

[Note 44] The same document, 1.6.9: "For people aged 85 and older consider treatment with" (the drug and dose that follow are not reproduced here), followed immediately by "Be aware of factors that may make treatment inappropriate (see recommendations 1.5.1 and 1.5.2)".

[Note 45] The same document, 1.5.1 and 1.5.2:

1.5.1 Make decisions about starting statin treatment after an informed discussion between the clinician and the person about the risks and benefits of statins.

1.5.2 Take into account potential benefits from lifestyle changes, the person's preferences, the presence of any comorbidities, whether they are on multiple medications, whether they are frail and their life expectancy. (See also NICE's guideline on multimorbidity.)

[Note 46] The same document, 1.6.1:

For primary prevention of CVD aim for a greater than 40% reduction in non-HDL cholesterol.

[Note 47] Hospital Authority Drug Formulary:

General drugs — drugs with proven efficacy and safety for the patients' relevant clinical conditions and available for general use. Public hospitals and clinics charge a standard fee when providing them. (our translation from the Chinese original)

Chinese original:

「通用藥物 — 經證實對病人有關臨床情況適用和有效，並可供一般使用的藥物。公立醫院和診所提供這類藥物時，會收取標準費用。」

[Note 48] Chronic Disease Co-Care Pilot Scheme, frequently asked questions:

For screening of cardiovascular risk factors (hypertension, hyperglycaemia and dyslipidaemia), the family doctor charges a scheme participant a one-off co-payment of 120 dollars, or of less than 120 dollars, at their first subsidised consultation in the screening stage or screening activity, covering all consultations, laboratory tests, diagnosis and the drawing up of a management plan in the screening stage. A scheme participant pays only that co-payment throughout the screening stage or screening activity, with the rest subsidised by the government. After the Chronic Disease Co-Care Pilot Scheme extended its scope of service to lipid testing, the co-payment a participant pays is unchanged. (our translation from the Chinese original)

Chinese original:

「就心血管疾病風險因素（高血壓、高血糖和高血脂）篩查，家庭醫生只會在計劃參加者於篩查階段／篩查活動接受首次資助診症時向其收取一次性為120元或少於120元的共付額，當中包括篩查階段所有診症、化驗檢查、診斷和制訂管理計劃的費用。計劃參加者在整個篩查階段／篩查活動只需支付該筆共付額，其餘費用由政府資助。」 「慢病共治計劃擴大服務範圍至血脂檢查後，計劃參加者所需支付的共付額費用不變。」

[Note 49] The same source:

People aged 45 or above who have not been diagnosed with diabetes or hypertension may enrol in the Chronic Disease Co-Care Pilot Scheme at a District Health Centre or Station, or at the clinic of a family doctor who has joined the scheme and offers enrolment for participants. (our translation from the Chinese original)

Chinese original:

「年滿45歲或以上以及沒有已被確診患有糖尿病／高血壓人士可到地區康健中心／站，或到已加入慢病共治計劃並有提供參加者登記服務的家庭醫生診所登記加入慢病共治計劃。」

[Note 50] The scheme's introduction page:

Only where dyslipidaemia reaches a specified level … up to 4 subsidised consultations in the first "personal scheme year", and up to 2 subsidised consultations a year from the second "personal scheme year" (our translation from the Chinese original)

Chinese original:

「只有血脂異常達特定水平的情況 … 首個「個人計劃年度」最多4次資助診症，由第二個「個人計劃年度」起每年最多2次資助診症」

[Note 51] The same source:

The cost of these drugs is included in the co-payment for a subsidised consultation in the treatment stage, so that even where a scheme participant is prescribed several drugs at once, no additional drug charge is payable. (our translation from the Chinese original)

Chinese original:

「這些藥物的費用已包含在治療階段的資助診症的共付額內，即使計劃參加者同時獲處方多種藥物，均無需支付額外藥物費用。」

#Matters on which this article makes no statement

The following are commonly seen but find no support in the material cited here, and are therefore not stated:

• "High cholesterol rose from 8.4% to 51.9% in 20 years." The 8.4% is the purely self-reported, doctor-diagnosed proportion of 2003/04, from a survey that did no lipid testing; the 51.9% is a composite of self-report plus laboratory testing. They do not measure the same thing. The two comparable series are given in the body.
• A prevalence of familial hypercholesterolaemia in Hong Kong of "about 1 in 250". Nothing in the material cited here, from any Hong Kong government source or local journal, supports that figure. 1 in 250 is an internationally quoted figure, not a Hong Kong one.
• The physical signs of familial hypercholesterolaemia (xanthelasma, Achilles tendon xanthoma, corneal arcus and so on). No source cited here lists those signs, so they are not reproduced. The hypertension reference framework lists familial hypercholesterolaemia only as one of the "very high risk" clinical conditions, without giving a way of recognising it. No self-checking symptom list can be used to rule that diagnosis in or out.
• An "ideal level" for triglycerides of "< 1.7 mmol/L". The ideal-level table in the Centre for Health Protection's Cholesterol leaflet has no triglyceride row. The figure of 1.7 mmol/L does appear in the same body's Non-Communicable Diseases Watch of October 2023, but as the statistical cut-off the Population Health Survey used to count the proportion with "raised triglyceride concentration", not as an ideal level published to the public. The two are not interchangeable.
• "HDL above 1.0 for men and above 1.3 for women" as a target. That sex-split pair is the statistical definition the Population Health Survey used to count the proportion with "low high-density lipoprotein concentration"; the ideal level the Centre for Health Protection gives the public is the same for both sexes, "above 1.0 (1.6 or above is more ideal)".
• The four-tier LDL target table as a standard "used in Hong Kong". That table is ESC/EAS 2019's targets, reproduced in the hypertension reference framework as one of several international guidelines and marked "for reference". Hong Kong has adopted none of them.
• "ESC SCORE2 or the Framingham Risk Score are commonly used clinically in Hong Kong". The Hong Kong hypertension reference framework (Revised Edition 2021) cites the older SCORE and does not mention SCORE2; the same document also states that there is no locally recalibrated tool.
• Percentages by which lifestyle intervention lowers LDL (cutting saturated fat, soluble fibre, weight loss, each 5%–10% and so on). The Hong Kong material cited here publishes no such LDL percentage effects.
• Statin muscle aching at "5%–10%". That figure corresponds to no published quantity: the reporting rate is about 27% in both arms (CTT 2022), and the excess attributable to the drug is about 11 per 1000 person-years in the first year.
• Significant statin-induced liver injury at "< 0.5%". The figure the Hong Kong hypertension reference framework publishes is that raised hepatic transaminase occurs in 0.5%–2% of cases (an endpoint of enzyme elevation, which is not the same as significant liver injury).
• The formulary category, subsidy status or cost of PCSK9 inhibitors in Hong Kong. The formulary search results above did not cover that class.
• The specific entry values for dyslipidaemia in the Chronic Disease Co-Care Pilot Scheme (for example "LDL ≥ 4.1 mmol/L"). The scheme's public pages say "where dyslipidaemia reaches a specified level" without stating a value.
• Market prices for home blood pressure monitors or private lipid testing. This article quotes no retail price.
• Comparisons of the potency of red yeast rice, omega-3 supplements and the like. The material cited here contains no such comparative data.
• The prescribing risk thresholds in the USPSTF recommendation and in NICE NG238, and the drugs and doses that recommendation names. This is not because they could not be found — both rules have been obtained, can be quoted word for word, and are clearly sourced. They are not reproduced because they are judgement rules written for clinicians rather than a chart for readers to apply to themselves: the input to both is a ten-year cardiovascular risk score, and Hong Kong's own official document states that there is at present no risk assessment tool designed for Chinese populations and no locally recalibrated version. If a person calculates a score online and checks it against a threshold, then "below the threshold, so I need not bother" is a self-exclusion made with a foreign rule; and "above the threshold, so I should take drug X at dose Y" is a prescribing decision. Neither is a conclusion those two documents were written to let a reader draw. The rules exist, can be consulted in the original, and are used by doctors; what this article reports is what each guideline is based on, and that those bases are not interchangeable. What is not reproduced is only the threshold values and the corresponding drugs and doses. The two recommendations that follow the threshold in NG238 — 1.6.8, "Do not rule out treatment" (treatment must not be ruled out merely because a score is below the threshold), and 1.6.9, considering treatment at 85 and above, together with the 1.5.1 and 1.5.2 to which both point — are reproduced in the body, because they contain no threshold to check oneself against and point the opposite way from self-exclusion.

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#Disclaimer

This article is health education information only and is not any form of pharmaceutical advertising. This platform does not promote or recommend the use of any particular drug, treatment or medical device for the conditions described above.

免責聲明 本文僅供一般資訊用途，並不構成醫療建議。如需診斷或治療，請諮詢合資格的香港註冊醫生。

Disclaimer This article is for general information only and does not constitute medical advice. Consult a qualified Hong Kong-registered doctor for diagnosis or treatment.

免责声明 本文仅供一般信息用途，并不构成医疗建议。如需诊断或治疗，请咨询合资格的香港注册医生。

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#Sources

• Report of the Population Health Survey for the three years to 2022 (Part II), Non-Communicable Disease Branch, Centre for Health Protection, Department of Health (year on the report cover 2023): https://www.chp.gov.hk/files/pdf/dh_phs_2020-22_part_2_report_chi_rectified.pdf (retrieved: 2 August 2026) — the three prevalence bases of 51.9%, 41.0% and 52.8%; the composition of 15.7% and 36.2%; the classification rule of TC ≥ 5.2 mmol/L; the age-standardised 45.0% (TC ≥ 5.0); mean lipid values; the age distribution and the fall after 55 to 64
• Report of Population Health Survey 2020-22 (Part II), Centre for Health Protection, Department of Health: https://www.chp.gov.hk/files/pdf/dh_phs_2020-22_part_2_report_eng_rectified.pdf (retrieved: 2 August 2026) — the English counterpart of the above
• Report on Population Health Survey 2003/2004, Department of Health: https://www.chp.gov.hk/files/pdf/report_on_population_health_survey_2003_2004_en.pdf (retrieved: 2 August 2026) — the 8.4% as a self-reported doctor-diagnosed proportion; that survey did no lipid testing
• Non-Communicable Diseases Watch, August 2019, "Blood Lipid Disorders", Centre for Health Protection: https://www.chp.gov.hk/files/pdf/ncd_watch_august_2019.pdf (retrieved: 2 August 2026) — self-reported 14.8% and composite 49.5% for 2014/15
• Non-Communicable Diseases Watch, October 2023, "Cholesterol and the risk of ischaemic stroke", Centre for Health Protection: https://www.chp.gov.hk/files/pdf/ncd_watch_oct_2023_chin.pdf and the English version https://www.chp.gov.hk/files/pdf/ncd_watch_oct_2023_eng.pdf (retrieved: 2 August 2026; the Chinese text retrieved again on 3 August 2026, 1,760,546 bytes) — the Chinese original of "as many as 70%" unaware; the Chinese original recommending regular lipid monitoring for people aged 50 to 75 as a higher-risk group; and the survey cut-offs by which, among people aged 15 to 84, TC ≥ 5.2 was 42.4%, LDL ≥ 3.4 was 30.0%, low HDL was 15.8% and TG ≥ 1.7 was 18.6% (statistical definitions, not ideal levels)
• Cholesterol leaflet (revised 2025), Centre for Health Protection: https://www.chp.gov.hk/files/her/exnnutp036_tc.pdf and the English version https://www.chp.gov.hk/files/her/exnnutp036_en.pdf (retrieved: 2 August 2026) — the "ideal levels" for total cholesterol, LDL and HDL; the absence of a triglyceride row; the statement that evidence on dietary cholesterol is insufficient, together with the method of counting eggs, squid, prawns and crabs and the "ask a healthcare professional" sentence within the same item; the sentence that the ill effect of saturated fat is greater than that of dietary cholesterol; and the fat limits on a 2000 kcal basis with the enquiry prompt in the same cell
• Hong Kong Reference Framework for Hypertension Care for Adults in Primary Care Settings, Revised Edition 2021 (Module 9 — Lipid Management in Hypertensive Patients, English version): https://www.healthbureau.gov.hk/phcc/rfs/src/pdfviewer/web/pdf/hypertensioncareforadults/en/13_en_RF_HT_full.pdf (retrieved: 2 August 2026) — Hong Kong's position of setting no lipid targets; the reproduction of international guidelines in table 3; the statement that risk tools do not apply to Chinese populations; the magnitude of effect of each class of lipid-lowering drug; the statin monitoring protocol and liver enzyme figures; the local adherence observation and the monitoring requirement in the sentence after it; the lifestyle fat targets; secondary causes to be identified first; the "Remarks" column of table 3 (NCEP and JBS2 commonly used as reference in public sectors; the ESC/EAS supplement on an LDL-C below 1.0 after a second vascular event within two years); the complete sets of items for ezetimibe and PCSK9 inhibitors; the note within the relative contraindications cell; the headache and dyspepsia cell of symptom monitoring; and the "Simvastatin dose limitations" page (which cites its source as FDA Drug Safety Communication, 15 Dec 2011). The nine professional modules of this document exist only in English
• Hong Kong Reference Framework for Hypertension Care for Adults in Primary Care Settings [patient version] (revised July 2022), Primary Healthcare Commission: https://www.healthbureau.gov.hk/phcc/rfs/src/pdfviewer/web/pdf/educationalresources/tc/05_tc_c_hypertension_care_patient.pdf (retrieved: 2 August 2026) — the Chinese definitions of blood lipids and dyslipidaemia
• Hong Kong Reference Framework for Preventive Care for Older Adults in Primary Care Settings (Revised Edition 2021), summary of recommendations: https://www.healthbureau.gov.hk/phcc/rfs/src/pdfviewer/web/pdf/preventivecareforolderadults/tc/02_coredocument/03_tc_ref_framework_adults_SUMMARY_OF_RECOMMENDATIONS.pdf (retrieved: 2 August 2026) — dyslipidaemia screening for ages 50 to 75, every three years, and more frequently where risk factors are present
• Hong Kong Reference Framework for Preventive Care for Older Adults in Primary Care Settings (Revised Edition 2021), full document: https://www.healthbureau.gov.hk/phcc/rfs/src/pdfviewer/web/pdf/preventivecareforolderadults/tc/02_coredocument/13_tc_ref_framework_adults.pdf (retrieved: 3 August 2026) — the complete list of cardiovascular risk factors in the "#" footnote on page 42; page 37 on individual factors in starting screening; page 42 on using the various cardiovascular assessment tools developed from the Framingham study
• Hospital Authority Drug Formulary categories and charges: https://www.ha.org.hk/hadf/tc/Drug-Formulary/Drug-Formulary-Categories-And-Charges.html and the English version https://www.ha.org.hk/hadf/en/Drug-Formulary/Drug-Formulary-Categories-And-Charges.html (retrieved: 2 August 2026) — the definition of general drugs; formulary search results showing simvastatin, atorvastatin, rosuvastatin and ezetimibe as general drugs
• Hospital Authority fee schedule (effective 1 January 2026): https://www.ha.org.hk (Content_ID=10045; retrieved: 2 August 2026) — family medicine clinic 150 dollars and 5 dollars per drug; specialist outpatient 250 dollars and 20 dollars per drug; an out-of-pocket cap of 10,000 dollars per calendar year
• Chronic Disease Co-Care Pilot Scheme frequently asked questions and scheme introduction, Primary Healthcare Commission: https://www.primaryhealthcare.gov.hk/cdcc/tc/gp/faq.html and https://www.primaryhealthcare.gov.hk/cdcc/tc/gp/introduction.html (retrieved: 2 August 2026) — the 120 dollar screening co-payment covering lipid testing; eligibility from 45; the number of subsidised consultations for dyslipidaemia; drug costs on the specified list being included in the co-payment; the government's recommended treatment co-payment of 150 dollars
• Yan BPY, Lau KK, Luk AOY, Wong MCS. Call to action: bridging gaps in lipid management in Hong Kong. Hong Kong Med J 2024;30:90–3 (DOI 10.12809/hkmj245158): https://www.hkmj.org/system/files/hkmj245158.pdf (retrieved: 2 August 2026) — the source of the comparison from 8.4% to 51.9%; that paper also contains a unit misprint (mmol/dL)
• Cholesterol Treatment Trialists' (CTT) Collaboration. Lancet 2012;380:581-90 (PMID 22607822; DOI 10.1016/S0140-6736(12)60367-5) — the rate ratio of 0.79 per 1.0 mmol/L LDL reduction; 11 fewer per 1000 over five years in the low-risk group, and the three authorial conclusions immediately after it (benefit greatly exceeding known hazards, such people not typically regarded as suitable under present guidelines, and those guidelines perhaps needing reconsideration); myopathy about 0.5 per 1000 over five years, rhabdomyolysis about 0.1, an annual excess of haemorrhagic stroke of the order of 0.5 per 1000 treated over five years, and a proportional increase of about 10% in the diagnosis of diabetes mellitus
• Cholesterol Treatment Trialists' (CTT) Collaboration. Lancet 2010 (PMID 21067804) — the excess of rhabdomyolysis per 10,000 (14 against 9; 14 against 6)
• Cholesterol Treatment Trialists' (CTT) Collaboration. Effect of statin therapy on muscle symptoms. Lancet 2022;400(10355):832-845 (PMID 36049498) — 27.1% against 26.6%; RR 1.03; 1.07 in the first year; 0.99 after the first year; 11 per 1000 person-years; more than 90% not caused by the statin; the small risks of muscle symptoms being much lower than the known cardiovascular benefits; myopathy 0.08% against 0.04% (RR 1.74) and about one extra case per 10,000 person-years; 2–3 cases of rhabdomyolysis per 100,000 person-years
• Ridker PM, and others. JUPITER. N Engl J Med 2008 (PMID 18997196) — 142/8,901 against 251/8,901; muscle symptoms 16.0% against 15.4%
• Cannon CP, and others. IMPROVE-IT. N Engl J Med 2015 (PMID 26039521) — 32.7% against 34.7% (7-year Kaplan–Meier estimates); all-cause deaths 1,215 against 1,231
• Sabatine MS, and others. FOURIER. N Engl J Med 2017 (PMID 28304224) — 9.8% against 11.3%; all-cause deaths 3.2% against 3.1%; muscle-related events 5.0% against 4.8%
• Law M, Rudnicka AR. (PMID 16581329) — rhabdomyolysis at 3.4 per 100,000 person-years
• ESC/EAS Guidelines for the management of dyslipidaemias. European Heart Journal 2019;41:111; 2025 Focused Update, European Heart Journal 2025;46:4359 — the LDL-C target values; non-HDL-C targets being 0.8 mmol/L higher than LDL-C targets; the 2025 move to stratification by SCORE2 and SCORE2-OP
• USPSTF, Statin Use for the Primary Prevention of Cardiovascular Disease in Adults (23 August 2022; JAMA 2022;328(8):746–753) — no lipid target; whether to prescribe a statin decided by age, at least one cardiovascular risk factor and a ten-year cardiovascular risk threshold (the threshold value is not reproduced here; see "matters on which this article makes no statement")
• NICE NG238, Lipid modification (published 14 December 2023; the date carried on the document is Published: 14 December 2023): https://www.nice.org.uk/guidance/ng238 (retrieved: 3 August 2026) — the primary prevention target of a greater than 40% reduction in non-HDL cholesterol (1.6.1); the two parallel absolute values for LDL cholesterol and non-HDL cholesterol in secondary prevention (1.7.1); 1.6.8 on not ruling out treatment merely because a ten-year risk score is below the threshold, and its two situations; 1.6.9 on considering treatment at 85 and above, pointing to 1.5.1 and 1.5.2; 1.5.1 on the informed discussion between clinician and person; 1.5.2 on lifestyle, preferences, comorbidities, multiple medications, frailty and life expectancy (the prescribing threshold value and the corresponding drugs and doses are not reproduced here; see "matters on which this article makes no statement")
• 2018 AHA/ACC Guideline on the Management of Blood Cholesterol — based on percentage reduction, with no LDL target value; units of mg/dL

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#Further reading

• On this platform: Reading laboratory and imaging reports
• On this platform: Hypertension
• On this platform: The Chronic Disease Co-Care Pilot Scheme (CDCC)
• Hong Kong Population Health Survey 2020-22 (Part II): chp.gov.hk PHS 2020-22
• Centre for Health Protection — Non-Communicable Diseases Watch: chp.gov.hk NCD watch
• Hong Kong Medical Journal — study on gaps in lipid management: hkmj.org — the source of the comparison from 8.4% to 51.9% that the section above does not accept; to check for yourself why this article does not accept that comparison, read the original (that paper also contains a unit misprint: mmol/dL)