Hypercholesterolemia (literally: high blood cholesterol) is the presence of high levels of cholesterol in the blood. It is not a disease but a metabolic derangement that can be secondary to many diseases and can contribute to many forms of disease, most notably cardiovascular disease. It is closely related to the terms “hyperlipidemia” (elevated levels of lipids) and “hyperlipoproteinemia” (elevated levels of lipoproteins).
Elevated cholesterol in the blood is due to abnormalities in the levels of lipoproteins, the particles that carry cholesterol in the bloodstream. This may be related to diet, genetic factors (such as LDL receptor mutations in familial hypercholesterolemia) and the presence of other diseases such as diabetes and an underactive thyroid. The type of hypercholesterolemia depends on which type of particle (such as low density lipoprotein) is present in excess.
LDL cholesterol is called “bad” cholesterol, because elevated levels of LDL cholesterol are associated with an increased risk of coronary heart disease. LDL lipoprotein deposits cholesterol on the artery walls, causing the formation of a hard, thick substance called cholesterol plaque. Over time, cholesterol plaque causes thickening of the artery walls and narrowing of the arteries, a process called atherosclerosis.
HDL cholesterol is called the “good cholesterol” because HDL cholesterol particles prevent atherosclerosis by extracting cholesterol from the artery walls and disposing of them through the liver. Thus, high levels of LDL cholesterol and low levels of HDL cholesterol (high LDL/HDL ratios) are risk factors for atherosclerosis, while low levels of LDL cholesterol and high level of HDL cholesterol (low LDL/HDL ratios) are desirable.
Total cholesterol is the sum of LDL (low density) cholesterol, HDL (high density) cholesterol, VLDL (very low density) cholesterol, and IDL (intermediate density) cholesterol.
High cholesterol levels are treated with diets low in cholesterol, medications, and rarely with other treatments including surgery (for particular severe subtypes). This has also increased emphasis on other risk factors for cardiovascular disease, such as high blood pressure.
What causes High cholesterol?
High cholesterol levels are due to a variety of factors including heredity, diet, and lifestyle. Less commonly, underlying illnesses affecting the liver, thyroid, or kidney may affect blood cholesterol levels.
- Heredity: Genes may influence how the body metabolizes LDL (bad) cholesterol. Familial hypercholesterolemia is an inherited form of high cholesterol that may lead to early heart disease.
- Weight: Excess weight may modestly increase your LDL (bad) cholesterol level. Losing weight may lower LDL and raise HDL (good) cholesterol levels.
- Physical activity/exercise: Regular physical activity may lower triglycerides and raise HDL cholesterol levels.
- Age and sex: Before menopause, women usually have lower total cholesterol levels than men of the same age. As women and men age, their blood cholesterol levels rise until about 60-65 years of age. After about age 50 years, women often have higher total cholesterol levels than men of the same age.
- Alcohol use: Moderate (1-2 drinks daily) alcohol intake increases HDL (good) cholesterol but does not lower LDL (bad) cholesterol. Doctors don’t know for certain whether alcohol also reduces the risk of heart disease. Drinking too much alcohol can damage the liver and heart muscle, lead to high blood pressure, and raise triglycerid levels. Because of the risks, alcoholic beverages should not be used as a way to prevent heart disease.
- Mental stress: Several studies have shown that stress raises blood cholesterol levels over the long term. One way that stress may do this is by affecting your habits. For example, when some people are under stress, they console themselves by eating fatty foods. The saturated fat and cholesterol in these foods contribute to higher levels of blood cholesterol.
What are the Symptoms of High cholesterol?
Elevated cholesterol does not lead to specific symptoms unless it has been longstanding. Some types of hypercholesterolemia lead to specific physical findings: xanthoma (deposition of cholesterol in patches on the skin or in tendons), xanthelasma palpabrum (yellowish patches around the eyelids) and arcus senilis (white discoloration of the peripheral cornea).
Longstanding elevated hypercholesterolemia leads to accelerated atherosclerosis; this can express itself in a number of cardiovascular diseases: coronary artery disease (angina pectoris, heart attacks), stroke and short stroke-like episodes and peripheral vascular disease.
Diagnosis
A blood test to check cholesterol levels — called a lipid panel or lipid profile — typically reports:
- Total cholesterol
- LDL cholesterol
- HDL cholesterol
- Triglycerides — a type of fat in the blood
For the most accurate measurements, don’t eat or drink anything (other than water) for nine to 12 hours before the blood sample is taken.
Interpreting the numbers
Cholesterol levels are measured in milligrams (mg) of cholesterol per deciliter (dL) of blood in the United States and some other countries. Canada and most European countries measure cholesterol in millimoles (mmol) per liter (L) of blood. Consider these general guidelines when you get your lipid panel (cholesterol test) results back to see if your cholesterol falls in ideal levels.
| Total cholesterol (U.S. and some other countries) |
Total cholesterol* (Canada and most of Europe) |
|
| Below 200 mg/dL | Below 5.2 mmol/L | Best |
| 200-239 mg/dL | 5.2-6.2 mmol/L | Borderline high |
| 240 mg/dL and above | Above 6.2 mmol/L | High |
| LDL cholesterol (U.S. and some other countries) |
LDL cholesterol* (Canada and most of Europe) |
|
| Below 70 mg/dL | Below 1.8 mmol/L | Best for people at high risk of heart disease |
| Below 100 mg/dL | Below 2.6 mmol/L | Best for people at risk for heart disease |
| 100-129 mg/dL | 2.6-3.3 mmol/L | Near ideal |
| 130-159 mg/dL | 3.4-4.1 mmol/L | Borderline high |
| 160-189 mg/dL | 4.1-4.9 mmol/L | High |
| 190 mg/dL and above | Above 4.9 mmol/L | Very high |
| HDL cholesterol (U.S. and some other countries) |
HDL cholesterol* (Canada and most of Europe) |
|
| Below 40 mg/dL (men) Below 50 mg/dL (women) |
Below 1 mmol/L (men) Below 1.3 mmol/L (women) |
Poor |
| 50-59 mg/dL | 1.3-1.5 mmol/L | Better |
| 60 mg/dL and above | Above 1.5 mmol/L | Best |
| Triglycerides (U.S. and some other countries) |
Triglycerides* (Canada and most of Europe) |
|
| Below 150 mg/dL | Below 1.7 mmol/L | Best |
| 150-199 mg/dL | 1.7-2.2 mmol/L | Borderline high |
| 200-499 mg/dL | 2.3-5.6 mmol/L | High |
| 500 mg/dL and above | Above 5.6 mmol/L | Very high |
*Canadian and European guidelines differ slightly from U.S. guidelines. These conversions are based on U.S. guidelines.
LDL targets differ
Because LDL cholesterol is a major risk factor for heart disease, it’s the main focus of cholesterol-lowering treatment. Your target LDL number can vary, depending on your underlying risk of heart disease.
Most people should aim for an LDL level below 130 mg/dL (3.4 mmol/L). If you have other risk factors for heart disease, your target LDL may be below 100 mg/dL (2.6 mmol/L). If you’re at very high risk of heart disease, you may need to aim for an LDL level below 70 mg/dL (1.8 mmol/L). In general, the lower your LDL cholesterol level is, the better.
You’re considered to be at a high risk of heart disease if you:
- Have had a previous heart attack or stroke
- Have artery blockages in your neck (carotid artery disease)
- Have artery blockages in your arms or legs (peripheral artery disease)
In addition, two or more of the following risk factors might also place you in the high-risk group:
- Smoking
- High blood pressure
- Low HDL cholesterol
- Diabetes
- Family history of early heart disease
- Age older than 45 if you’re a man, or older than 55 if you’re a woman
- Elevated lipoprotein (a), another type of fat (lipid) in your blood
Children and cholesterol testing
Children as young as age 2 can have high cholesterol, but not all children need to be screened for high cholesterol. The American Academy of Pediatrics recommends a cholesterol test (fasting lipid panel) for children between the ages of 2 and 10 who have a known family history of high cholesterol or premature coronary artery disease. Your child’s doctor may recommend retesting if your child’s first test shows he or she has normal cholesterol levels.
The American Academy of Pediatrics also recommends testing if the child’s family history for high cholesterol is unknown, but the child has risk factors for high cholesterol, such as obesity, high blood pressure or diabetes.
Methods of Treatment
Self-Care at Home
High cholesterol is just one of several risk factors for coronary heart disease. A health care practitioner will consider a person’s overall risk when assessing their cholesterol levels and discussing treatment options.
Risk factors are conditions that increase a person’s risk for developing heart disease. Some risk factors can be changed and others cannot. In general, the more risk factors a person has, the greater the chance of developing coronary heart disease. Some risk factors can be controlled; however, some cannot be controlled.
- Risk factors that cannot be cannot control include:
-
- age (45 years or older for men; 55 years or older for women); and
- family history of early heart disease (father or brother affected before age 55 years; mother or sister affected before age 65 years).
- Risk factors that can be controled include:
-
- high blood cholesterol (high total cholesterol and high LDL [bad] cholesterol);
- low HDL (good) cholesterol;
- quit smoking;
- high blood pressure;
- diabetes;
- obesity/excess weight; and
- physical inactivity.
If a person has high lipoproteins and thus high cholesterol, their doctor will work with them to target their levels with dietary and drug treatment. Depending on a person’s risk factors for heart disease, target goals may differ for lowering thier LDL cholesterol.
Diet
The National Cholesterol Education Program has created dietary guidelines.
- NCEP dietary guidelines are:
- total fat: less than than 30% of daily caloric intake
- saturated fat: less than 7% of daily caloric intake
- polyunsaturated fat (found in vegetables, nuts, seeds, fish, leafy greens): less than or equal to 10% of daily caloric intake
- monounsaturated fat: approximately 10%-15% of daily caloric intake
- cholesterol: less than 200 milligrams per day
- carbohydrates: 50%-60% of daily caloric intake
- Some people are able to reduce fat and dietary cholesterol with vegetarian diets.
- Stanol esters can be included in the diet and may reduce LDL by about 14%. Products containing stanol esters include margarine substitutes (marketed as brand names Benecol and Take Control).
- People with higher triglycerides may benefit from a diet that is higher in monounsaturated fat and lower in carbohydrates, particularly simple sugars. A common source of monounsaturated fat is olive oil.
Activity
Although exercise has little effect on LDL, aerobic exercise may improve insulin sensitivity, HDL, and triglyceride levels and may thus reduce the risk of heart disease. People who exercise and control their diet appear to be more successful with long-term lifestyle modifications that improve their heart risk profile.
Medication
Lifestyle changes such as exercising and eating a healthy diet are the first line of defense against high cholesterol. But, if you’ve made these important lifestyle changes and your total cholesterol — and particularly your LDL cholesterol — remains high, your doctor may recommend medication.
The specific choice of medication or combination of medications depends on various factors, including your individual risk factors, your age, your current health and possible side effects. Common choices include:
- Statins. Statins — among the most commonly prescribed medications for lowering cholesterol — block a substance your liver needs to make cholesterol. This causes your liver to remove cholesterol from your blood. Statins may also help your body reabsorb cholesterol from built up deposits on your artery walls, potentially reversing coronary artery disease. Choices include atorvastatin (Lipitor), fluvastatin (Lescol), lovastatin (Altoprev, Mevacor), pravastatin (Pravachol), rosuvastatin (Crestor) and simvastatin (Zocor).
- Bile-acid-binding resins. Your liver uses cholesterol to make bile acids, a substance needed for digestion. The medications cholestyramine (Prevalite, Questran), colesevelam (Welchol) and colestipol (Colestid) lower cholesterol indirectly by binding to bile acids. This prompts your liver to use excess cholesterol to make more bile acids, which reduces the level of cholesterol in your blood.
- Cholesterol absorption inhibitors. Your small intestine absorbs the cholesterol from your diet and releases it into your bloodstream. The drug ezetimibe (Zetia) helps reduce blood cholesterol by limiting the absorption of dietary cholesterol. Zetia can be used in combination with any of the statin drugs.
- Combination cholesterol absorption inhibitor and statin. The combination drug ezetimibe-simvastatin (Vytorin) decreases both absorption of dietary cholesterol in your small intestine and production of cholesterol in your liver. It’s unknown whether Vytorin is more effective in reducing heart disease risk than taking simvastatin by itself.
Medications for high triglycerides
If you also have high triglycerides, your doctor may prescribe:
- Fibrates. The medications fenofibrate (Lofibra, TriCor) and gemfibrozil (Lopid) decrease triglycerides by reducing your liver’s production of very-low-density lipoprotein (VLDL) cholesterol and by speeding up the removal of triglycerides from your blood. VLDL cholesterol contains mostly triglycerides.
- Niacin. Niacin (Niaspan) decreases triglycerides by limiting your liver’s ability to produce LDL and VLDL cholesterol. Prescription and over-the-counter niacin is available, but prescription niacin is preferred as it has the least side effects. Dietary supplements containing niacin that are available over-the-counter are not effective for lowering triglycerides, and may damage your liver.
- Omega-3 fatty acid supplements. Omega-3 fatty acid supplements can help lower your cholesterol. You can take over-the-counter supplements, or your doctor may prescribe Lovaza, a prescription omega-3 fatty acid supplement, as a way to lower your triglycerides. Lovaza may be taken with another cholesterol-lowering medication, such as a statin. If you choose to take over-the-counter supplements, get your doctor’s OK first. Omega-3 fatty acid supplements could affect other medications you’re taking.
Effectiveness varies
Most cholesterol medications are well tolerated, but effectiveness varies from person to person. The common side effects are muscle pains, stomach pain, constipation, nausea and diarrhea. If you decide to take cholesterol medication, your doctor may recommend liver function tests every few months to monitor the medication’s effect on your liver.
Clinical practice guidelines
Various clinical practice guidelines have addressed the treatment of hypercholesterolemia. The American College of Physicians has addressed hypercholesterolemia in patients with diabetes. Their four recommendations are:
- Lipid-lowering therapy should be used for secondary prevention of cardiovascular mortality and morbidity for all patients (both men and women) with known coronary artery disease and type 2 diabetes.
- Statins should be used for primary prevention against macrovascular complications in patients (both men and women) with type 2 diabetes and other cardiovascular risk factors.
- Once lipid-lowering therapy is initiated, patients with type 2 diabetes mellitus should be taking at least moderate doses of a statin (the accompanying evidence report states “simvastatin, 40 mg/d; pravastatin, 40 mg/d; lovastatin, 40 mg/d; atorvastatin, 20 mg/d; or an equivalent dose of another statin”).
- For those patients with type 2 diabetes who are taking statins, routine monitoring of liver function tests or muscle enzymes is not recommended except in specific circumstances.
The National Cholesterol Education Program revised their guidelines; however, their 2004 revisions have been criticized for use of nonrandomized, observational data.
In the UK, the National Institute for Health and Clinical Excellence (NICE) has made recommendations for the treatment of elevated cholesterol levels, published in 2008.
Alternative medicine
A survey by the National Center for Complementary and Alternative Medicine focused on who used complementary and alternative medicine (CAM), what was used, and why it was used in the United States by adults age 18 years and over during 2002. According to this survey, CAM was used to treat cholesterol by 1.1% of U.S. adults who used CAM during 2002. Consistent with previous studies, this study found that the majority of individuals (i.e., 54.9%) used CAM in conjunction with conventional medicine.
A review of 84 clinical trials with phytosterols and/or phytostanols reported an average of 8.8% lowering of LDL-cholesterol with a mean daily intake of 2.15 grams/day, administered 2-3 times a day with meals. The dose:response figure shows that more than half of the response is achieved once intake is more than 1.0 g/day. In 2000 the Food and Drug Administration approved a Qualified Health Claim for labeling of foods containing specified amounts of phytosterol esters or phytostanol esters as cholesterol lowering; in 2003 an FDA Interim Health Claim Rule extended that label claim to foods or dietary supplements delivering more than 0.8 grams/day of either esterified or non-esterified (“free”) phytosterols or phytostanols divided over two doses per day. Some researchers, however, are concerned about diet supplementation with plant sterol esters and draw attention to significant safety issues. This is why Health Canada, the federal department responsible for helping Canadians maintain and improve their health, has not allowed these foods to be sold in Canada.
Children and cholesterol treatment
Diet and exercise are the best initial treatment for children age 2 and older who have high cholesterol or who are obese. The American Academy of Pediatrics also recommends treatment with prescription drugs, such as statins, for children age 8 and older if a child has a high level of LDL cholesterol. However, this recommendation is controversial. The long-term effects of cholesterol-lowering drugs have not been extensively studied in children. In addition, certain cholesterol medications such as niacin are not recommended for children. Because of the disagreement in the medical community on this topic, talk to your child’s doctor about the best way to lower your child’s cholesterol.
Drugs rating:
| Title | Votes | Rating | ||
| 1 | Colestid (Colestipol) | 15 |
|
(9.2/10) |
| 2 | Lescol (Fluvastatin) | 1 |
|
(9.0/10) |
| 3 | Questran (Cholestyramine) | 49 |
|
(8.4/10) |
| 4 | Prevalite (Cholestyramine) | 10 |
|
(8.2/10) |
| 5 | Advicor (Lovastatin and Niacin) | 7 |
|
(8.0/10) |
| 6 | Slo-Niacin (Niacin) | 6 |
|
(7.7/10) |
| 7 | Caduet (Amlodipine and Atorvastatin) | 26 |
|
(7.2/10) |
| 8 | Lipitor (Atorvastatin) | 349 |
|
(7.1/10) |
| 9 | Lipofen (Fenofibrate) | 7 |
|
(6.9/10) |
| 10 | Crestor (Rosuvastatin) | 376 |
|
(6.7/10) |
| 11 | Zocor (Simvastatin) | 219 |
|
(6.5/10) |
| 12 | Lopid (Gemfibrozil) | 27 |
|
(6.5/10) |
| 13 | Mevacor (Lovastatin) | 13 |
|
(6.2/10) |
| 14 | Niaspan (Niacin) | 74 |
|
(6.1/10) |
| 15 | Vytorin (Ezetimibe and Simvastatin) | 11 |
|
(6.1/10) |
| 16 | TriCor (Fenofibrate) | 84 |
|
(5.9/10) |
| 17 | Zetia (Ezetimibe) | 131 |
|
(5.7/10) |
| 18 | WelChol (Colesevelam) | 94 |
|
(5.7/10) |
| 19 | Pravachol (Pravastatin) | 35 |
|
(5.7/10) |
| 20 | Trilipix (Fenofibric Acid) | 60 |
|
(5.2/10) |
| 21 | Antara (Fenofibrate) | 10 |
|
(5.2/10) |
| 22 | Simcor (Niacin and Simvastatin) | 27 |
|
(5.1/10) |
| 23 | Niacor (Niacin) | 1 |
|
(3.0/10) |
| 24 | Fenoglide (Fenofibrate) | 0 |
|
(0/10) |
| 25 | Altocor (Lovastatin) | 0 |
|
(0/10) |
| 26 | Monopril HCT (Fosinopril and Hydrochlorothiazide) | 0 |
|
(0/10) |
| 27 | Triglide (Fenofibrate) | 0 |
|
(0/10) |
| 28 | Fibricor (Fenofibric acid) | 0 |
|
(0/10) |
| 29 | Altoprev (Lovastatin) | 0 |
|
(0/10) |
| 30 | Lofibra (Fenofibrate) | 0 |
|
(0/10) |
| 31 | Colestid Flavored (Colestipol) | 0 |
|
(0/10) |
Prevention
The same heart-healthy lifestyle changes that can lower your cholesterol can help prevent you from having high cholesterol in the first place. To help prevent high cholesterol, you can:
- Lose extra pounds and maintain a healthy weight
- Quit smoking
- Eat a low-fat, low-salt diet that includes many fruits, vegetables and whole grains
- Exercise on most days of the week for at least 30 minutes
- Drink alcohol in moderation, if at all