Hyperlipidemia

Hyperlipidemia, also known as high cholesterol, is a common condition where there are too many fats in your blood. While it usually has no symptoms, it can lead to serious problems like heart attack and stroke if left untreated. The good news is that with healthy lifestyle changes and sometimes medication, you can manage your cholesterol levels and protect your heart.

Table of contents

• What is Hyperlipidemia?
• How Common is This Condition?
• What Causes Hyperlipidemia?
• Signs and Symptoms
• How is Hyperlipidemia Diagnosed?
• Why is High Cholesterol Serious?
• Treatment and Management
• Lifestyle Changes to Lower Cholesterol
• Medications for High Cholesterol
• Prevention

What is Hyperlipidemia?

Hyperlipidemia means you have too many lipids (fats) in your blood. Your body contains several types of lipids, including cholesterol and triglycerides (another type of fat in your blood)^[1]. Your liver makes cholesterol naturally to help you digest food and produce hormones. However, you also get cholesterol from foods you eat, especially from meat and dairy products^[1].

The term hyperlipidemia is often used interchangeably with dyslipidemia or high cholesterol^[1]. While cholesterol is essential for building healthy cells, having too much of it in your blood can cause problems^[8].

dyslipidemia, high cholesterol

There are different types of cholesterol that travel through your blood^[1]:

• Low-density lipoprotein (LDL) is known as “bad” cholesterol. It can clog your arteries by causing hardened cholesterol deposits called plaque to collect inside your blood vessels. When LDL cholesterol levels are borderline high (130 to 159 mg/dL) or high (160 to 189 mg/dL), it increases your risk for heart problems^[1].
• Very low-density lipoprotein (VLDL) is also considered bad cholesterol because it carries triglycerides that add to plaque buildup in your arteries^[1].
• High-density lipoprotein (HDL) is known as “good” cholesterol. It helps remove excess cholesterol from your blood by carrying it to your liver, which gets rid of it. You don’t want your HDL level to be lower than 40 mg/dL^[1].

Total cholesterol levels of 200 to 239 mg/dL are considered borderline high, and 240 mg/dL or above is high^[1]. For adults and children, a total cholesterol above 200 mg/dL may be considered high^[6]. Optimal total blood cholesterol is around 150 mg/dL^[6].

How Common is This Condition?

Hyperlipidemia is very common. In the United States, 93 million adults aged 20 and older have a total cholesterol count above the recommended limit of 200 mg/dL^[1]. Another report indicates that 29 million (12.4%) of American adults had elevated total cholesterol between 2015 and 2016^[14].

More specifically, 71 million (33.5%) U.S. adults had elevated LDL cholesterol levels, but only about 33% of these individuals had their levels controlled^[14]. About 18.4% of American adults had low HDL levels (less than 40 mg/dL)^[14].

What Causes Hyperlipidemia?

Hyperlipidemia can be classified as either primary (familial) or secondary (acquired)^[3]. Primary hyperlipidemia comes from genetic disorders that you may inherit from your parents. Secondary hyperlipidemia develops due to lifestyle factors or other medical conditions.

Lifestyle factors that can contribute to high cholesterol include^[5]:

• Eating foods high in cholesterol, saturated fats, and trans fats, such as cheese, egg yolks, fried and processed foods, ice cream, pastries, and red meat
• Smoking
• Drinking too much alcohol
• Being overweight or obese
• Not getting enough exercise
• Being under stress

Medical conditions that can affect your cholesterol levels include^[5]:

• Diabetes
• Liver disease
• Problems with your pancreas
• Multiple myeloma
• Polycystic ovary syndrome (PCOS)
• Hypothyroidism
• Lupus
• Kidney disease
• Sleep apnea
• HIV
• Primary biliary cholangitis (a gallbladder problem)

Some medications you take for other conditions can also affect your cholesterol levels, including steroids, beta-blockers, diuretics, hormonal birth control, and antiretrovirals for HIV^[5].

Hyperlipidemia can run in families. People who inherit the condition can get very high cholesterol levels and have a much greater chance of having a heart attack, even when they’re young^[5].

Signs and Symptoms

High cholesterol has no symptoms^[8]. Most people with high cholesterol feel perfectly well and often have no symptoms^[3]. A blood test is the only way to find out if you have it^[8].

This is why it’s sometimes called a “silent killer”—you can have dangerously high cholesterol levels without knowing it, allowing plaque to build up in your arteries over time^[14].

How is Hyperlipidemia Diagnosed?

Your healthcare provider will diagnose hyperlipidemia through a blood test called a lipid panel or lipid profile^[11]. This test usually measures^[11]:

• Total cholesterol
• Low-density lipoprotein (LDL) cholesterol
• High-density lipoprotein (HDL) cholesterol
• Triglycerides

In general, you may need to fast (not eat or drink anything except water) for around 9 to 12 hours before the test. Some cholesterol tests don’t require fasting, so follow your healthcare provider’s instructions^[11].

The American Heart Association recommends that children get screened 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 conditions such as diabetes or obesity^[8]. The next screening is recommended between ages 17 and 21, and then regularly for adults^[8].

For people aged 45 years and older, you can have your cholesterol checked as part of a Heart Health Check with your doctor. If you identify as Aboriginal or Torres Strait Islander, you should have your cholesterol checked from age 18 years^[3].

Why is High Cholesterol Serious?

Hyperlipidemia can be very serious if it’s not managed. As long as high cholesterol is untreated, plaque continues to accumulate inside your blood vessels^[1]. Too much cholesterol isn’t healthy because it can create blockages in your arteries where blood travels throughout your body, damaging organs that don’t receive enough blood^[1].

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^[6]. When blood flow to the heart is blocked, it can cause chest pain (also called angina) or a heart attack^[6]. The plaque itself can become irritated or inflamed, which can cause a blood clot to form around it. This can cause a stroke or heart attack depending on where the blockage is^[1].

High cholesterol increases your risk for heart disease and stroke, two leading causes of death in the United States^[6]. Cardiovascular disease is the leading cause of death among Americans^[1].

Elevated levels of LDL cholesterol consistently increase a person’s risk for developing atherosclerotic plaques and subsequent vascular disease^[3]. High cholesterol can lead to atherosclerotic disease, which may increase the risk of acute coronary events^[14].

Treatment and Management

Treatment of hyperlipidemia involves both lifestyle changes and, when necessary, medication^[3]. Managing your cholesterol is a long-term effort^[1]. Hyperlipidemia is treatable, but it’s often a lifelong condition. You’ll need to watch what you eat and exercise regularly. You might need to take prescription medication as well^[5].

The goal is to lower harmful cholesterol levels. Doing so can reduce your risk of heart disease, heart attack, stroke, and other problems^[5]. It’s important to know that healthcare providers consider other factors in addition to your cholesterol numbers when they make treatment decisions^[1].

You might need medicine to lower your cholesterol if your cholesterol level has not gone down after changing your diet and lifestyle, or if you’re at high risk of having a heart attack or stroke^[16]. Each patient’s LDL cholesterol goal depends on their overall cardiovascular risk, and medical therapy should be individually tailored^[3].

Lifestyle Changes to Lower Cholesterol

Lifestyle changes are the foundation of hyperlipidemia management and are recommended as initial therapy in most patients^[3]. Changing what you eat and what you do every day can effectively lower your lipids and minimize the risk of stroke and heart disease^[19].

Follow a heart-healthy diet

Making changes to your diet can reduce cholesterol and improve your heart health^[18]:

• Reduce saturated fats. Saturated fats are found primarily in red meat and full-fat dairy products. Decreasing your consumption of saturated fats can reduce your LDL cholesterol. Limit saturated fats to less than 7% of your daily calories^[18].
• Eliminate trans fats. Trans fats, sometimes listed on food labels as “partially hydrogenated vegetable oil,” raise overall cholesterol levels^[18].
• Increase healthy fats. Replace saturated fats and trans fats with polyunsaturated and monounsaturated fats. When cooking, use olive oil or canola oil because they contain monounsaturated fats that can help reduce LDL levels^[19].
• Eat foods rich in omega-3 fatty acids. Include foods like salmon, mackerel, herring, walnuts, and flaxseeds. You might also consider eating 6 ounces of salmon or tuna twice per week, or taking an omega-3 supplement on other days^[13].
• Increase soluble fiber. Soluble fiber can reduce the absorption of cholesterol into your bloodstream. It’s found in foods such as oatmeal, kidney beans, and other legumes^[18]. Aim for about 3 ounces of oats per day or consider psyllium supplements^[23].
• Increase soy protein. Try to include about 1.5 ounces of soy protein per day, using tofu and soy foods to replace meat^[23].
• Add tree nuts. Include about 1.5 ounces of almonds, walnuts, or pecans per day to your diet^[23].
• Increase plant stanols and sterols. These are found in fortified foods like certain margarines and spreads. Aim for about 1 ounce per day of products like Promise Activ or Benecol spread^[23].
• Limit dietary cholesterol. Avoid full-fat dairy products, fried foods, and processed foods such as sausage or bacon that are high in saturated fat^[19].
• Eat more fruits and vegetables. Add more fruits and vegetables to increase your fiber and vitamin intake^[19].

Experts recommend that people eat as little dietary cholesterol as possible. Your body makes all the cholesterol it needs, so the cholesterol in foods you eat is extra^[6].

Maintain a healthy weight

Being overweight or obese raises levels of LDL cholesterol and can lower HDL cholesterol. Excess body fat affects how your body uses cholesterol and slows down your body’s ability to remove LDL cholesterol from your blood^[22]. Losing weight can help reduce cholesterol levels^[19].

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 and work together on a food and fitness plan to help you reach or maintain a healthy weight^[22].

Get regular physical activity

Physical activity can help you maintain a healthy weight and lower your cholesterol and blood pressure levels^[22]. Regular aerobic exercise has beneficial effects on lipid levels, particularly if performed for at least 120 minutes per week^[23].

For adults, aim for 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^[22]. Make physical activity part of each day—take the stairs instead of the elevator, park a little farther away, or walk to the store^[22].

Your total cholesterol levels can decrease if you do 40 minutes of moderate to vigorous exercise 3 to 4 days a week, or a total of 150 minutes weekly^[19].

Quit smoking

Smoking damages your blood vessels, speeds up the hardening of the arteries, and greatly increases your risk for heart disease^[22]. Smoking can increase triglycerides and decrease HDL cholesterol levels, and the risk of heart disease is higher with smoking^[19]. Talk with your doctor about ways to help you quit^[22].

Limit alcohol

Too much alcohol can raise cholesterol levels and levels of triglycerides. Avoid drinking too much alcohol. Men should have no more than two drinks per day, and women should have no more than one^[22]. Moderate consumption—one drink per day for women and two per day for men—may have some benefits^[23].

Medications for High Cholesterol

When lifestyle changes alone are not enough to control cholesterol levels, your doctor may prescribe medication^[19]. Several types of cholesterol-lowering drugs are available:

Statins are the most common medicine for high cholesterol. They reduce the amount of cholesterol your body makes and are usually taken once a day. You usually need to take them for life^[16]. Statins have the most convincing data for prevention of cardiovascular disease^[13]. High-dose statins should be initiated in patients with acute coronary syndrome^[13].

Other medications may be used if statins don’t work or you don’t want to take statins. These include^[16]:

• Other tablets such as ezetimibe, fibrates, bile acid sequestrants (also called resins), and bempedoic acid
• Injections such as alirocumab, evolocumab, and inclisiran

Widely used LDL cholesterol-lowering drugs include statins, ezetimibe, bempedoic acid, and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors^[12].

It’s important to note that fibrates and niacin have not been shown to reduce all-cause mortality in secondary prevention, but may be useful additions when statins alone cannot adequately control lipid levels^[13]. Omega-3 fatty acids may be a good alternative after heart attack for patients who cannot tolerate statins^[13].

Prevention

By living a healthy lifestyle, you can help keep your cholesterol in a healthy range and prevent high cholesterol^[22]. The same lifestyle changes recommended for treatment can also help prevent hyperlipidemia:

• Eat a heart-healthy diet low in saturated and trans fats
• Maintain a healthy weight
• Get regular physical activity
• Don’t smoke
• Limit alcohol consumption

Work with your healthcare team to prevent and manage high cholesterol. Discuss your other medical conditions and any medicines you are taking, and bring a list of questions to your appointments^[22].

It’s increasingly important to control elevated cholesterol levels to decrease the prevalence of cardiovascular disease and the incidence of coronary events^[14]. Following key principles can help: the sooner you start lowering LDL cholesterol the greater the benefit, the greater the decrease in LDL cholesterol the greater the benefit, and the higher your absolute risk of cardiovascular disease the greater the benefit^[12].