Cholesterol Management: Causes, Risks, and Treatment of High Cholesterol

What is Cholesterol?

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Cholesterol is a waxy, fat-like substance found in every cell of our body. Despite its bad reputation, it’s actually essential for life:

• Cell membrane structure: It’s a fundamental component of cell membranes
• Hormone production: Used in making hormones like estrogen, testosterone, and cortisol
• Vitamin D synthesis: Plays a role in vitamin D production with sunlight
• Bile acids: Used in making bile acids necessary for fat digestion

About 75-80% of cholesterol is produced by the liver; the rest comes from diet.

Types of Cholesterol

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Cholesterol is transported in the blood by carrier molecules called lipoproteins. The main types are:

LDL Cholesterol (“Bad” Cholesterol)

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Low-density lipoprotein (LDL) carries cholesterol from the liver to tissues. Excess LDL accumulates in artery walls and leads to atherosclerosis (hardening of arteries).

LDL Target Values:

HDL Cholesterol (“Good” Cholesterol)

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High-density lipoprotein (HDL) collects excess cholesterol from tissues and returns it to the liver. This “reverse cholesterol transport” protects the arteries.

HDL Target Values:

• Men: > 40 mg/dL
• Women: > 50 mg/dL
• Ideal: > 60 mg/dL

Triglycerides

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A type of fat the body uses to store energy. High triglyceride levels also increase cardiovascular risk.

Triglyceride Values:

Total Cholesterol

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The sum of LDL, HDL, and a portion of triglycerides. Used as a general indicator.

Total Cholesterol:

• Ideal: < 200 mg/dL
• Borderline high: 200-239 mg/dL
• High: ≥ 240 mg/dL

Causes of High Cholesterol

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High cholesterol can result from many factors:

Non-Modifiable Factors

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• Genetics: Hereditary conditions like familial hypercholesterolemia
• Age: Cholesterol levels increase with age
• Gender: Generally lower in premenopausal women

Modifiable Factors

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• Diet: Diet rich in saturated fats, trans fats, and cholesterol
• Obesity: Excess weight increases LDL and decreases HDL
• Physical inactivity: Sedentary lifestyle lowers HDL
• Smoking: Lowers HDL and increases LDL oxidation
• Diabetes: Poor blood sugar control disrupts lipid profile
• Hypothyroidism: Thyroid hormone deficiency increases cholesterol

Risks of High Cholesterol

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High cholesterol, especially high LDL, leads to plaque buildup in artery walls (atherosclerosis):

Coronary Artery Disease

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• Narrowing of arteries feeding the heart
• Chest pain (angina)
• Heart attack (myocardial infarction)

Cerebrovascular Disease

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• Narrowing or blockage of brain arteries
• Stroke
• Transient ischemic attack (TIA)

Peripheral Artery Disease

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• Narrowing of leg arteries
• Leg pain while walking (claudication)
• Gangrene in severe cases

Other Complications

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• Renal artery disease
• Erectile dysfunction
• Mesenteric ischemia (intestinal blood flow impairment)

Diagnosis and Evaluation

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Cholesterol levels are measured with a simple blood test:

Lipid Panel

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• Fasting requirement: Generally 9-12 hours of fasting recommended
• Measured values: Total cholesterol, LDL, HDL, triglycerides
• Calculated values: Non-HDL cholesterol, LDL/HDL ratio

How Often Should Testing Be Done?

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• Adults over 20: Every 4-6 years
• If risk factors present: More frequently (annually)
• If on treatment: Every 4-12 weeks (initially), then every 3-12 months

Cardiovascular Risk Assessment

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Not just cholesterol, but total risk should be evaluated:

• SCORE2 risk calculator: Used in Europe
• Framingham risk score: Common in the US
• Factors evaluated: Age, gender, smoking, blood pressure, diabetes, family history

Treatment Approaches

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Cholesterol management includes lifestyle modifications and, when necessary, medication therapy:

Lifestyle Modifications

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Forms the foundation of treatment for all patients:

1. Heart-Healthy Diet

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Foods to Reduce:

• Saturated fats: Red meat, full-fat dairy, butter (<7% of daily calories)
• Trans fats: Margarine, fried foods, packaged snacks (avoid completely)
• Cholesterol: Organ meats, egg yolks (<200 mg daily)

Foods to Increase:

• Fiber: Oats, legumes, fruits, vegetables (25-30 grams daily)
• Omega-3 fatty acids: Fatty fish (2-3 servings weekly)
• Plant sterols: Fortified margarines, yogurts
• Nuts: Walnuts, almonds (a handful daily)

Mediterranean Diet:

• Olive oil as main fat source
• Plenty of fruits, vegetables, whole grains
• Moderate fish and poultry
• Limited red meat
• Moderate wine (optional)

2. Regular Physical Activity

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• At least 150 minutes of moderate aerobic exercise weekly
• Or 75 minutes of vigorous exercise
• Increases HDL, lowers triglycerides
• Helps with weight control

3. Weight Control

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• Losing even 5-10% of excess weight improves lipid profile
• Waist circumference targets: <40 inches (102 cm) for men, <35 inches (88 cm) for women
• BMI target: 18.5-24.9

4. Quit Smoking

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• Smoking lowers HDL
• Increases LDL oxidation
• Benefits of quitting begin immediately

5. Alcohol Restriction

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• Excessive alcohol increases triglycerides
• Men: No more than 2 standard drinks daily
• Women: No more than 1 standard drink daily

Medication Therapy

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When lifestyle changes are insufficient or in high-risk patients, medication is needed:

Statins (HMG-CoA Reductase Inhibitors)

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The cornerstone of cholesterol-lowering therapy:

Low-Moderate Intensity Statins:

• Simvastatin 10-20 mg
• Pravastatin 10-40 mg
• Lovastatin 20-40 mg
• Fluvastatin 40-80 mg

High Intensity Statins:

• Atorvastatin 40-80 mg
• Rosuvastatin 20-40 mg

Effect: Lowers LDL by 30-50%

Side Effects:

• Muscle pain (myalgia) - most common
• Liver enzyme elevation - rare
• Diabetes risk - slight increase
• Rhabdomyolysis - very rare but serious

Ezetimibe

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• Reduces cholesterol absorption from intestines
• Can be used with statins
• Lowers LDL by additional 15-20%
• Few side effects

PCSK9 Inhibitors

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• Evolocumab (Repatha)
• Alirocumab (Praluent)
• Injection form (every 2-4 weeks)
• Lowers LDL by 50-60%
• Added to statins or for statin intolerance
• Expensive, covered for specific indications

Bempedoic Acid

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• New generation oral medication
• Alternative for statin intolerance
• Less muscle side effects
• Lowers LDL by 15-25%

Fibrates

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• Effective in lowering triglycerides
• Fenofibrate, gemfibrozil
• Increases HDL
• Preferred for high triglycerides

Omega-3 Fatty Acids (Prescription)

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• High-dose EPA/DHA
• Lowers triglycerides
• Reduction in cardiovascular events (in some studies)

Combination Therapy

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When target not reached with single drug:

• Statin + Ezetimibe (most common)
• Statin + PCSK9 inhibitor
• Statin + Fibrate (careful use)

Special Situations

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Familial Hypercholesterolemia (FH)

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• Genetic cholesterol elevation
• Very high LDL from birth
• Risk of early heart disease
• Requires aggressive treatment
• Family screening important

Diabetic Dyslipidemia

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• High triglycerides, low HDL, small dense LDL
• Blood sugar control is priority
• Statin therapy recommended for most diabetic patients

Chronic Kidney Disease

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• Lipid metabolism is disrupted
• Statin doses should be adjusted
• Some medications may be contraindicated

Pregnancy

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• Statins are contraindicated
• Lifestyle changes are priority
• Bile acid sequestrants if needed

Treatment Monitoring

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Initial Evaluation

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• Baseline lipid panel
• Liver function tests
• Muscle enzymes (CK) - baseline value
• Kidney function
• Thyroid function

Post-Treatment Follow-up

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• Lipid panel after 4-12 weeks
• If target reached, check every 6-12 months
• CK and liver tests if side effects suspected

Reaching Targets

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• Reaching LDL target is priority
• Non-HDL cholesterol is secondary target
• Triglyceride control

Frequently Asked Questions (FAQ)

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When Should You See a Doctor?

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Cardiology evaluation is recommended in the following situations:

• Family history of early heart disease
• High cholesterol detected
• Existing heart disease or diabetes
• Experiencing statin side effects
• Not reaching targets despite treatment

Regular cholesterol monitoring and appropriate treatment significantly reduce heart disease risk.

If you have questions about your cholesterol levels or would like to schedule an evaluation, please feel free to contact me.