BACKGROUND: Heterozygous familial hypercholesterolemia (HeFH) is an autosomal dominant disease characterized by elevated low-density lipoprotein cholesterol (LDL-C) that increases risk for clinically significant atherosclerotic cardiovascular disease (ASCVD). This common (1:220) disease is present within the fighter pilot community and hesitation to treat this condition at younger ages results in a higher risk for coronary artery disease (CAD), the presence of which can be catastrophic for flying safety. CASE REPORT: A 40-yr-old asymptomatic F-15 pilot presented with persistently elevated LDL-C levels > 190 mg dL1 and a significant family history of CAD. Coronary artery calcium, CT angiography, and finally, invasive angiography were used to further stratify him as having mild CAD. Initiation of statin therapy significantly lowered his LDL and subsequent risk for disease progression, allowing him to return to flying. DISCUSSION: Early recognition and treatment of HeFH is imperative for lowering the risk of ASCVD. Often the medical community supporting flyers is hesitant to diagnose or treat this condition, due to nonrecognition, the young age of presentation, or reluctance to potentially ground a flyer. By intervening earlier, rather than waiting, aviators can remain on flying status longer with lower risk to themselves and their aircrew. Gatzke LC. Heterozygous familial hyperlipidemia in a fighter pilot. Aerosp Med Hum Perform. 2021; 92(10):835837.