OBJECTIVES: European guidelines recommend statins as first-line treatment for elevated cholesterol in patients at high cardiovascular (CV) risk; however, many patients do not attain guideline-recommended goals on statin monotherapy. As atorvastatin is now generically-available and its use is likely to increase, we examined recommended total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C) levels in high-risk patients treated with atorvastatin monotherapy in the UK. METHODS: In this retrospective UK general practice database study, included were patients with a prescription for atorvastatin monotherapy (IndexRx) between 11/30/08-11/30/11, who had evidence of coronary heart disease (CHD), atherosclerotic vascular disease (AVD), diabetes mellitus (DM), or familial hypercholesterolemia, ≥1 TC and LDL-C measurement 3-12 months post-IndexRx, and an atorvastatin prescription (to determine the daily dose) within 45 days of lipid measurements. Endpoints included proportions of patients (overall and by dose) below guideline-specific thresholds: TC<5.0, TC<4.0, and for patients with CHD/AVD+DM, TC<4.0 or LDL<2.0 mmol/L. RESULTS: Of 2,999 high-risk patients (60.2% males, mean age 67.9 years [SD 10.6]) meeting selection criteria, 23.9, 28.2, 36.2, and 11.6% received prescriptions for 10-mg, 20-mg, 40-mg, and 80-mg atorvastatin, respectively. Further, 27.6% of patients were newly initiated with atorvastatin monotherapy at index date. Overall, mean follow-up TC was 4.08 (SD 0.80) and LDL-C was 2.08 (SD 0.65) mmol/L. The proportion of patients with TC<5.0 and <4.0 mmol/L was 88.8% and 45.8%, respectively. For those with CHD/AVD+DM, 63.7% had TC<4.0 or LDL-C<2.0 mmol/L. Generally, more patients were below lipid thresholds with higher atorvastatin doses.  CONCLUSIONS: In UK patients at high CV risk, a substantial proportion did not achieve guideline-recommended lipid levels. Less than half of patients achieved TC<4.0 mmol/L, and only two-thirds of patients with CHD/AVD+DM were below recommended levels for either TC or LDL-C. More effective lipid-lowering strategies may be needed to achieve optimal TC and LDL-C levels in high-risk patients.