Hypercholesterolaemia
Hypercholesterolaemia is a common condition where there is too much “bad” cholesterol in your blood. It affects nearly one-third of adults and significantly increases the risk of heart attacks and strokes. The good news is that most people can manage it through lifestyle changes, and effective medications are available when needed.
Table of contents
- What is hypercholesterolaemia?
- Types of cholesterol
- Who is affected?
- Symptoms
- Causes and risk factors
- How is it diagnosed?
- Health problems caused by high cholesterol
- Treatment options
- Lifestyle changes to lower cholesterol
- Medications for high cholesterol
- Prevention
What is hypercholesterolaemia?
Hypercholesterolaemia is a lipid disorder (a condition affecting fats in the blood) where your low-density lipoprotein (LDL), or “bad cholesterol,” is too high[1]. This makes fat collect in your arteries in a process called atherosclerosis, which puts you at higher risk of heart attack and stroke[1]. Atherosclerosis is the main cause of cardiovascular disease, which is responsible for more deaths than anything else in the world[1].
Cholesterol is a waxy, fat-like substance made by your liver[5]. Your body needs cholesterol to perform important jobs, such as making hormones and digesting fatty foods. Your body makes all the blood cholesterol it needs[5].
What your healthcare provider considers hypercholesterolaemia depends on your other risk factors for cardiovascular disease. Providers classify all of these as high levels of low-density lipoprotein cholesterol: 190 mg/dL or higher without other risk factors, higher than 160 mg/dL with another major risk factor, or above 130 mg/dL with two risk factors[1].
Hypercholesterolaemia is a type of hyperlipidemia that focuses specifically on high LDL cholesterol. Hyperlipidemia includes various disorders that feature high levels of fat in your blood, not just LDL[1].
Types of cholesterol
When you go to a healthcare professional to get your cholesterol checked, this test will usually check the levels of cholesterol and triglycerides (another type of fat in your blood) in your body[5].
Low-density lipoprotein (LDL) is known as “bad” cholesterol because having high levels of LDL cholesterol can lead to plaque buildup in your arteries and result in heart disease or stroke[5].
High-density lipoprotein (HDL) is known as “good” cholesterol because high levels of it can lower your risk of heart disease and stroke[5].
Triglycerides are a type of fat in your blood that your body uses for energy. The combination of high levels of triglycerides with either low HDL cholesterol or high LDL cholesterol levels can increase your risk for heart attack and stroke[5].
Total cholesterol is the total amount of cholesterol in your blood based on your HDL, LDL, and triglycerides numbers[5].
Who is affected?
Hypercholesterolaemia is very common. About 1 out of every 20 people has hypercholesterolaemia. Nearly one-third of American adults have high LDL cholesterol[1].
You’re more likely to have a high level of LDL cholesterol if you’re older than 40, Asian Indian, Filipino or Vietnamese, post-menopausal, or female[1]. You’re also more likely to get high cholesterol if you’re over 50, a man, or you’ve been through the menopause[3]. It can also run in families[3].
Symptoms
High cholesterol has no symptoms in most people[2]. A blood test is the only way to find out if you have it[2].
However, if you have severe hypercholesterolaemia, you may have cholesterol deposits on your eyelid skin called xanthelasma or on connective tissue called xanthoma. Also, you may have cholesterol in your eye, which is called a corneal arcus[1].
Causes and risk factors
Hypercholesterolaemia causes include your genes (pure or familial hypercholesterolaemia), a diet that includes a lot of saturated and/or trans fats, a lack of exercise, and tobacco products[1]. It can also be caused by eating fatty food, not exercising enough, being overweight, smoking and drinking alcohol[3].
High cholesterol can also be caused by several medical conditions including obstructive liver disease, diabetes, hypothyroidism (underactive thyroid gland), anorexia nervosa, chronic kidney failure, and nephrotic syndrome (a kidney disorder)[1].
Certain medications can also contribute to high cholesterol, including amiodarone, rosiglitazone, cyclosporine, and hydrochlorothiazide[1].
Important risk factors for high cholesterol include age (male 45 years or older, female 55 years or older), a positive family history of premature atherosclerotic cardiovascular disease (younger than 55 years in a male and younger than 65 years in a female), hypertension, diabetes, smoking, and low HDL cholesterol[7].
Certain health conditions such as type 2 diabetes and obesity can raise your risk for high cholesterol. Lifestyle factors, such as eating a diet high in saturated and trans fats and not getting enough activity, can also raise your risk for high cholesterol[5].
How is it diagnosed?
Usually at your annual physical exam, your healthcare provider will ask you about your medical history and your family’s health, do a physical exam, and order a lipid panel blood test, which you usually do after a period of fasting[1].
The standard test for diagnosing cholesterol disorders is called a lipid profile or a lipid panel. A lipid profile measures your total cholesterol (both LDL and HDL cholesterol) and triglycerides[8]. In general, you can’t have food or liquids other than water for around 9 to 12 hours before the test. This is called fasting. Some cholesterol tests don’t require fasting, so follow your healthcare professional’s instructions[10].
The American Heart Association recommends that children get checked for high cholesterol once between ages 9 and 11. Screening may start earlier if a child has a family history of high cholesterol, heart attack or stroke, or has conditions such as diabetes or obesity. The next cholesterol screening is recommended for people between ages 17 and 21. After that, many adults get their cholesterol checked regularly[2].
For people aged 45 years and over, you can have your cholesterol checked as part of a Heart Health Check with your GP. If you identify as Aboriginal and/or Torres Strait Islander, you should have your cholesterol checked from age 18 years[3].
Once your provider rules out other causes of your hypercholesterolaemia, they can do genetic testing. If you have pure hypercholesterolaemia (familial hypercholesterolaemia), your provider may suggest genetic testing for your family[1].
Health problems caused by high cholesterol
Having high blood cholesterol can lead to a buildup called “plaque” on the walls of your arteries (a type of blood vessel). As plaque builds up over time, the insides of your arteries narrow. This narrowing blocks blood flow to and from your heart and other organs. When blood flow to the heart is blocked, it can cause chest pain (also called angina) or a heart attack (also called myocardial infarction)[5].
High cholesterol also increases your risk for heart disease and stroke, two leading causes of death in the United States[5].
Hypercholesterolaemia can lead to cardiovascular issues such as stroke, coronary artery disease, and peripheral artery disease[1].
Treatment options
Hypercholesterolaemia treatment involves bringing down your LDL level to prevent heart disease[1]. Early and stepped-up treatment for hypercholesterolaemia is needed to lower LDL cholesterol and, in turn, lower the chance of a heart attack, stroke or early cardiovascular death. Without treatment, LDL cholesterol levels and risks to the heart and brain will be very high. So treatment is lifelong[16].
A first step is to cut LDL cholesterol by at least half. Overall, the main goal is to get your LDL below 100 mg/dL if you have hypercholesterolaemia and no other risk factors. If you have other risk factors, then the goal will be to get LDL to under 70 mg/dL[16].
If you are concerned about your cholesterol, talk to your health care team about steps you can take to manage your cholesterol. Treating high cholesterol often is managed by a combination of adjusting certain lifestyle factors and taking cholesterol-lowering medicines prescribed by a doctor[15].
Lifestyle changes to lower cholesterol
A healthy diet, regular exercise, weight loss and not smoking are known to lower cholesterol and carry a host of other health benefits. While these changes are essential for good health, lifestyle changes alone often aren’t enough with hypercholesterolaemia and need to be coupled with medications and other therapies[16].
You can lower your cholesterol by eating healthily and getting more exercise[3].
Healthy eating
To reduce your cholesterol, try to cut down on fatty food, especially food that contains a type of fat called saturated fat. You can still have foods that contain a healthier type of fat called unsaturated fat[22].
Try to eat more oily fish like mackerel and salmon, olive oil and rapeseed oil and spreads made from these oils, brown rice, wholegrain bread and wholewheat pasta, nuts and seeds, and fruits and vegetables[22].
Try to eat less meat pies, sausages and fatty meat, butter, lard and ghee, cream and hard cheese like cheddar, cakes and biscuits, and food that contains coconut oil or palm oil[22].
A few changes in your diet can reduce cholesterol and improve your heart health. Reduce saturated fats, which are found primarily in red meat and full-fat dairy products. Eliminate trans fats, sometimes listed on food labels as “partially hydrogenated vegetable oil,” which are often used in margarines and store-bought cookies, crackers and cakes[17].
Eat foods rich in omega-3 fatty acids, which don’t affect LDL cholesterol but have other heart-healthy benefits, including reducing blood pressure. Foods with omega-3 fatty acids include salmon, mackerel, herring, walnuts and flaxseeds[17].
Increase soluble fiber, which can reduce the absorption of cholesterol into your bloodstream. Soluble fiber is found in such foods as oatmeal, kidney beans, Brussels sprouts, apples and pears[17].
Physical activity
Aim to do at least 150 minutes (2.5 hours) of exercise a week. Some good things to try when starting out include walking (try to walk fast enough so your heart starts beating faster), swimming, and cycling[22].
Try a few different exercises to find something you like doing. You’re more likely to keep doing it if you enjoy it[22].
For adults, the Surgeon General recommends 2 hours and 30 minutes of moderate-intensity exercise, such as brisk walking or bicycling, every week. Children and adolescents should get 1 hour of physical activity every day[21].
Weight management
Overweight and obesity raise levels of LDL (“bad”) cholesterol. Excess body fat affects how your body uses cholesterol and slows down your body’s ability to remove LDL cholesterol from your blood. The combination raises your risk of heart disease and stroke[21].
To determine whether your weight is in a healthy range, doctors often calculate your body mass index (BMI). Talk with your doctor about what a healthy weight is for you. Work with your doctor on a food and fitness plan to help you reach or maintain a healthy weight[21].
Stop smoking
Smoking can raise your cholesterol and make you more likely to have serious problems like heart attacks, strokes and cancer[22]. Smoking damages your blood vessels, speeds up the hardening of the arteries, and greatly increases your risk for heart disease[21].
Limit alcohol
Too much alcohol can raise cholesterol levels and levels of triglycerides, a type of fat in the blood. Try to avoid drinking more than 14 units of alcohol a week, have several drink-free days each week, and avoid drinking lots of alcohol in a short time (binge drinking)[22]. Men should have no more than two drinks per day, and women should have no more than one[21].
Medications for high cholesterol
You might need medicine to lower your cholesterol if your cholesterol level has not gone down after changing your diet and lifestyle, or you’re at a high risk of having a heart attack or stroke[14].
Your treatment will likely include a combination of medications, depending on your type of hypercholesterolaemia and which medications have already been tried[16].
Statins
Statins are the most common medicine for high cholesterol. They reduce the amount of cholesterol your body makes[14]. Statins block an enzyme needed to produce cholesterol in the liver[16].
You take a tablet once a day. You usually need to take them for life[14]. The lowest dose of the weakest statin can lower cholesterol levels by 20%. Some high potency drugs can lower it by 50-60%[8].
Other cholesterol-lowering medications
Other medicines may be used if statins do not work or you do not want to take statins[14].
Ezetimibe blocks cholesterol from being absorbed in the gut[16].
Bile acid sequestrants (also called resins) help remove cholesterol from the body[16].
PCSK9 inhibitors (alirocumab or evolocumab) work by helping the body get rid of LDL cholesterol from the blood by blocking a protein in the liver called proprotein convertase subtilisin kexin 9[16].
Bempedoic acid is an adenosine triphosphate-citrate lyase inhibitor that helps stop cholesterol production in your liver. It can also be taken as a combination of bempedoic acid and ezetimibe[16].
Lomitapide inhibits the microsomal triglyceride transfer protein (MTP) to lower production in the liver and release of LDL cholesterol in the blood[16].
Evinacumab, an angiopoietin-like 3 (ANGPTL-3) inhibitor, allows faster breakdown of fats that lead to high cholesterol in the blood[16].
Inclisiran blocks production of the PCSK9 protein in the liver[16].
If you take medicine to treat high cholesterol, follow your health care team’s instructions carefully. Always ask your health care team questions if you don’t understand something. Never stop taking your medicine without first talking to your doctor, nurse, or pharmacist[15].
Prevention
By living a healthy lifestyle, you can help keep your cholesterol in a healthy range[21].
Your body makes all of the cholesterol it needs, so you do not need to obtain cholesterol through foods. Eating lots of foods high in saturated fat and trans fat may contribute to high cholesterol and related conditions, such as heart disease[21].
You and your health care team can work together to prevent high cholesterol. Discuss your other medical conditions and any medicines you are taking, and bring a list of questions to your appointments[21].
You may need to have your cholesterol levels tested at least once every 4 to 6 years if you do not have heart disease. Some people need to get their cholesterol checked more often or less often. Talk with your health care team about the timeline that is best for you[15].
