Hypercholesterolemia

Causes

• Unhealthy Diet:
  • High in Saturated Fats: Found in red meat, full-fat dairy products, processed foods, and some oils (e.g., coconut oil, palm oil). Saturated fats increase LDL cholesterol.
  • High in Trans Fats: Often found in commercially baked goods, fried foods, and some margarines. Trans fats raise LDL cholesterol and lower high-density lipoprotein (HDL) cholesterol (the "good" cholesterol).
  • High in Dietary Cholesterol: Foods like organ meats, egg yolks, and shellfish. While dietary cholesterol has less impact than saturated/trans fats, excessive intake can contribute.
• Lack of Physical Activity: Sedentary lifestyles can lower HDL cholesterol and increase LDL cholesterol.
• Obesity: Having a high body mass index (BMI) can increase LDL cholesterol and triglyceride levels and decrease HDL cholesterol.
• Smoking: Damages blood vessel walls, making them more likely to accumulate fatty deposits. It also lowers HDL cholesterol.
• Age: Cholesterol levels tend to rise with age in both men and women.
• Genetics (Familial Hypercholesterolemia - FH): An inherited disorder that causes very high LDL cholesterol levels from birth, leading to early onset of heart disease. It's caused by a defect in a gene that regulates how the body processes cholesterol.
• Certain Medical Conditions:
  • Chronic kidney disease.
  • Diabetes.
  • Hypothyroidism (underactive thyroid).
  • Polycystic ovary syndrome (PCOS).
  • Liver disease.
• Medications: Some medications can raise cholesterol levels, such as certain diuretics, beta-blockers, corticosteroids, and oral contraceptives.

Symptoms

• No Direct Symptoms: High cholesterol itself usually does not produce noticeable symptoms.
• Symptoms of Complications: Symptoms only appear when high cholesterol leads to conditions like atherosclerosis, which can cause:
  • Angina: Chest pain or discomfort if arteries supplying the heart are narrowed.
  • Heart Attack: If blood flow to the heart is completely blocked.
  • Stroke: If blood flow to the brain is blocked.
  • Peripheral Artery Disease (PAD): Pain in the legs during walking (claudication) if arteries to the limbs are narrowed.
  • Xanthomas: Fatty deposits under the skin (rare, typically seen in severe genetic forms).
  • Arcus Senilis: A white or gray arc around the cornea of the eye (also rare, can indicate high cholesterol in younger individuals).

Diagnosis

• Lipid Panel (or Lipid Profile) Blood Test: This test is usually done after a 9-12 hour fast to get accurate readings. It measures:
  • Total Cholesterol: The sum of all cholesterol in your blood.
  • Low-Density Lipoprotein (LDL) Cholesterol: Often called "bad" cholesterol. High levels lead to plaque buildup in arteries.
  • High-Density Lipoprotein (HDL) Cholesterol: Often called "good" cholesterol. It helps remove excess cholesterol from the arteries. Higher levels are better.
  • Triglycerides: A type of fat in the blood. High levels, especially when combined with high LDL or low HDL, can increase heart disease risk.
• Screening Guidelines:
  • Adults should typically have their cholesterol checked every 4-6 years, or more frequently if there are risk factors for heart disease.
  • Children and adolescents may be screened if they have a family history of high cholesterol or early heart disease, or if they have certain risk factors.
• Medical History and Physical Exam: The doctor will also consider your overall health, lifestyle, family history, and other risk factors for heart disease.

Treatment

• Lifestyle Modifications (First-line treatment):
  • Healthy Diet:
    • Reduce saturated and trans fats.
    • Increase soluble fiber (oats, beans, fruits).
    • Eat omega-3 fatty acid-rich foods (fatty fish like salmon, flaxseeds).
    • Include plant sterols/stanols (fortified foods).
    • Limit dietary cholesterol.
  • Regular Physical Activity: Aim for at least 150 minutes of moderate-intensity aerobic exercise per week.
  • Weight Management: Lose excess weight and maintain a healthy BMI.
  • Smoking Cessation: Quitting smoking can significantly improve HDL cholesterol levels and reduce cardiovascular risk.
  • Limit Alcohol Consumption: Excessive alcohol can increase triglyceride levels.
• Medications:
  • Statins (HMG-CoA Reductase Inhibitors): The most commonly prescribed and effective medications for lowering LDL cholesterol. Examples: atorvastatin (Lipitor), simvastatin (Zocor), rosuvastatin (Crestor).
  • Cholesterol Absorption Inhibitors: (e.g., ezetimibe - Zetia) Reduces the absorption of cholesterol from the small intestine. Often used in combination with statins.
  • PCSK9 Inhibitors: Injectable drugs (e.g., alirocumab - Praluent, evolocumab - Repatha) for very high LDL cholesterol, especially in patients with FH or those who cannot tolerate statins.
  • Bile Acid Sequestrants (Resins): (e.g., cholestyramine, colestipol, colesevelam) Bind to bile acids in the intestine, leading the liver to use more cholesterol to make new bile acids, thus lowering cholesterol.
  • Fibrates: (e.g., gemfibrozil, fenofibrate) Primarily used to lower high triglyceride levels and can slightly increase HDL.
  • Niacin (Nicotinic Acid): Can lower LDL and triglycerides and raise HDL, but often has bothersome side effects like flushing.
  • Omega-3 Fatty Acid Ethyl Esters: (e.g., Lovaza, Vascepa) Prescription-strength omega-3s to lower very high triglyceride levels.

Deciding Whether and How to Treat

A cholesterol number on its own does not decide treatment. What decides it is the risk of a heart attack or stroke over the next decade, which the number contributes to but does not determine, and a few tests and principles make that decision far clearer than it usually is.

Risk, not just the number

A statin is recommended outright when LDL is 190 mg/dL or above, for most people with diabetes between 40 and 75, and for anyone with existing coronary artery disease or a prior stroke. For everyone else a ten-year risk calculator combines age, blood pressure, smoking, and cholesterol, and treatment is discussed above a risk of about 7.5 percent. Family history of early heart disease, chronic kidney disease, inflammatory conditions, and a high lipoprotein(a), covered in our lipoprotein(a) article, all push the decision toward treating.

A calcium score settles the undecided cases

When the risk falls in the gray zone, a coronary artery calcium scan is a low-cost CT that shows whether plaque has actually formed. A score of zero allows most people to defer a statin safely, while a high score makes the case for one regardless of how the numbers look. It is the single most useful test for people reluctant to start medication on the basis of a calculation.

Statin side effects in proportion

Muscle aches are the commonest reason people stop a statin, yet in blinded trials most of that symptom burden appears on placebo as well. Genuine intolerance exists but is uncommon, and switching from atorvastatin to rosuvastatin, lowering the dose, or dosing on alternate days keeps most people on effective treatment. Our statin myths versus evidence article addresses the liver, diabetes, and memory concerns that circulate.

When a statin is not enough

Ezetimibe is added first, then a PCSK9 inhibitor injection, bempedoic acid, or twice-yearly inclisiran for people with established disease or familial hypercholesterolemia who remain above target. Familial hypercholesterolemia is more common than most people assume, at about one in 250, and finding it in one person means testing their parents, siblings, and children, because heart disease in that family starts decades early without treatment.

What diet can and cannot do

Replacing saturated fat with unsaturated fat, adding soluble fiber from oats, beans, and fruit, and using plant sterols each lower LDL by a meaningful amount, and together they can lower it by 10 to 20 percent. Dietary cholesterol itself matters less than once thought. Diet alone rarely reaches target in someone starting well above it, and it works alongside medication rather than instead of it. Our understanding cholesterol guide covers the practical choices, and the hypertriglyceridemia page covers the other half of the lipid panel. The NHLBI and the CDC publish patient guidance on testing and treatment.

If your cholesterol is high and you are unsure whether you need medication, or stopped a statin because of side effects, schedule a visit; there is usually a workable answer.