Cholesterol is a form of fat that is found in large amounts in animal products such as red meat, sausages, steaks, hamburgers, and eggs. The Western diet is generally high in foods that contain cholesterol. Over time, cholesterol and other fats may begin accumulating in the body resulting in a condition known as hypercholesterolemia. There are multiple forms of cholesterol; higher levels of LDL cholesterol is associated with various diseases. While lower levels of HDL cholesterol are associated with higher LDL levels and increased risk of heart diease. For this reason LDL cholesterol is commonly referred to as “bad cholesterol” and HDL cholesterol is referred to as “good cholesterol.” In reality, a healthy balance of both is essential for health.
Bad cholesterol (LDL) eventually deposits into the arteries all over our body. This leads to arterial injury, inflammation, and eventually the development of fatty arterial plaques known as atheromas, this condition is known as atherosclerosis.
Fatty plaques reduce blood flow to organs and tissues in our body, which reduces oxygen levels in these areas. Fatty plaques can also abruptly rupture, leading to complete blockage of arterial blood flow and lack of oxygen delivery to tissues causing tissues to die. This process can occur in the heart, brain, kidneys, gut, and limbs. A large number of heart attacks and strokes are due to the rupture of a plaque.
Since elevated cholesterol (hypercholesterolemia) has serious complications, it is important that patients understand its causes, symptoms, and treatment.
Elevated levels of cholesterol results from both genetics and diet. Certain individuals have genes passed down through their families that result in an increased risk for high cholesterol. This is why a diet filled with high cholesterol foods can lead to disease in some people but not in others. This is why hyperlipidemia commonly runs in families.
High cholesterol is commonly caused by foods that are high in animal fats, thee include:
- Red meats (e.g. steak, burgers, sausage)
- Dairy – Milk, Cheese, Ice cream
Hyperlipidemia is extremely common in the United States, it is difficult to estimate the exact number of people living with high cholesterol, as it is not detected until severe complications develop in many patients. High-cholesterol is frequently seen in the elderly and middle-aged population but can also affect adolescents. This is largely due to the Western diet and lifestyle which typically includes minimal physical activity and high-cholesterol foods. The biggest concern is that hyperlipidemia is a major risk factor for cardiovascular disease, including heart attack and stroke, which are two of the leading causes of death in the United States.
The symptoms and signs of high cholesterol can range from no symptoms at all, to complications such as heart attack and stroke. Patients are often asymptomatic and this disease is usually detected on routine labs ordered as part of a yearly physical. Those with extremely high levels of cholesterol for long periods of time may eventually show signs of it on their face. They often develop fatty plaque-like structures around the eye, which are called cholesteatomas.
The complications of high cholesterol have much more severe signs and symptoms. People with heart attacks usually have chest pain, difficulty breathing, nausea, and sweating. Individuals with stroke develop sudden one-sided weakness or numbness, confusion, trouble speaking or swallowing, and headaches. Patients with hypercholesterolemia are also at risk of developing peripheral vascular disease, which causes leg and calf cramps after walking certain distances due to poor circulation and ulcers on the tips of the toes due to loss of blood flow.
Your doctor will generally test for elevated cholesterol every few years by ordering a fasting lipid panel. Lipids are fats – a lipid panel tells your doctor which types of fats are elevated, normal, or low. Remember – HDL is good cholesterol and LDL is bad cholesterol. A high LDL is worrisome but a low HDL can also be concerning.
HDL is a good fat because it helps get rid of LDL and other bad cholesterol from our arteries, which helps reverse fatty plaque buildup. The fasting lipid panel also evaluates for other types of fat in the blood such as triglycerides – which can be important in people with a high risk of heart disease or certain genetic conditions.
Your doctor will also likely order blood tests such as a CMP (comprehensive metabolic panel), and screen you for diabetes. If your doctor is worried about a prior stroke or heart attack, they will probably obtain an ECG (electrocardiogram), chest x-ray, and ultrasound of the heart (echocardiogram).
High cholesterol is treated with dietary and lifestyle changes, as well as medications. Your doctor will likely recommend a low-sodium, low-cholesterol diet, rich in fruits and vegetables. They may also tell you to avoid red meat and encourage the intake of lean meats such as poultry and fish.
Your doctor typically evaluates for other cardiovascular risk factors such as older age, smoking history, diabetes, and a history of stroke or heart attack. If you smoke, they will advise tobacco cessation. They may recommend treatment with cholesterol-lowering drugs depending on your cardiovascular risk. The most common prescription for elevated cholesterol is a class of medications called statins, which include:
- Lipitor (atorvastatin)
- Lescol (fluvastatin)
- Mevacor (lovastatin)
- Pravachol (pravastatin)
- Crestor (rosuvastatin)
- Zocor (simvastatin)
Other, less commonly prescribed medications for elevated cholesterol include:
- Questran (cholestyramine)
- Colestid (colestipol)
- Lopid (gemfibrozil)
- Tricor (fenofibrate)
- Omega-3 fatty acids
These medications are almost always prescribed in addition to statins if the cholesterol does not sufficiently decrease after statins are begun. In some cases, patients with specific genetics will benefit from these medications over statins. These medications are also more likely to result in side effects compared to statins and may not be appropriate for all patients.
- Morris PB, Ballantyne CM2, Birtcher KK3. Review of clinical practice guidelines for the management of LDL-related risk.J Am Coll Cardiol. 2014 Jul 15;64(2):196-206.
- Keaney JF Jr1, Curfman GD, Jarcho JA. A pragmatic view of the new cholesterol treatment guidelines. N Engl J Med. 2014 Jan 16;370(3):275-8.