The extracts of red yeast rice represent a nutraceutical with proven cholesterol lowering effect. Its efficacy is proportional to the concentration on monacolin K in the extract that could reach the amount of 10 mg per daily dose. The daily assumption of monacolin K could then reduce LDL-cholesterol plasma levels by 15-25% in 6-8 weeks. The LDL-cholesterol reduction is associated with a proportional reduction in total cholesterolemia, non-HDL cholesterolemia, plasma apolipoprotein B, high-sensitivity C-reactive protein, and matrix metalloproteinases 2 and 9. Then, the red yeast rice lipid-lowering efficacy is associated with a significant improvement of endothelial function and pulse wave velocity, which are well-known and validated instrumental biomarkers of vascular aging. Beyond the cholesterol lowering efficacy and the statin-like mechanism of action, the risk of the use of monacolin K 10 mg per day are minimal, and mild myalgias could be foreseen only in frail patients previously intolerant to minimal statin dosages. In conclusion, red yeast rice titrated in monacolin K represents a good therapeutic tool for the management of moderate hypercholesterolemias in patients with low added cardiovascular disease risk.