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Hyperlipidemia
(high cholesterol)

Hyperlipidemia (high cholesterol) is an excess of lipids or fats in your blood. This can increase your risk of heart attack and stroke because blood can’t flow through your arteries easily. Adding exercise and healthy foods can lower your cholesterol. Some people need medication as well. Managing your cholesterol is a long-term effort.

Overview

What is hyperlipidemia?

Hyperlipidemia, also known as dyslipidemia or high cholesterol, means you have too many lipids (fats) in your blood. Your liver creates cholesterol to help you digest food and make things like hormones. But you also eat cholesterol in foods from the meat and dairy aisles. As your liver can make as much cholesterol as you need, the cholesterol in foods you eat is extra.

Too much cholesterol (200 mg/dL to 239 mg/dL is borderline high and 240 mg/dL is high) isn’t healthy because it can create roadblocks in your artery highways where blood travels around to your body. This damages your organs that don’t receive enough blood from your arteries.

Bad cholesterol (LDL) is the most dangerous type because it causes hardened cholesterol deposits (plaque) to collect inside of your blood vessels. This makes it harder for your blood to get through, which puts you at risk for a stroke or heart attack. The plaque itself can be irritated or inflamed, which can cause a clot to form around it. This can cause a stroke or heart attack depending on where the blockage is.

Think of cholesterol, a kind of fat, as traveling in lipoprotein cars through your blood.

Low-density lipoprotein (LDL) is known as bad cholesterol because it can clog your arteries like a large truck that broke down and is blocking a traffic lane. (Borderline high number: 130 mg/dL to 159 mg/dL. High: 160 mg/dL to 189 mg/dL.)

Very low-density lipoprotein (VLDL) is also called bad because it carries triglycerides that add to artery plaque. This is another type of traffic blocker.

High-density lipoprotein (HDL) is known as good cholesterol because it brings cholesterol to your liver, which gets rid of it. This is like the tow truck that removes the broken down vehicles from the traffic lanes so vehicles can move. In this case, it’s clearing the way for your blood to get through your blood vessels. For your HDL, you don’t want to have a number lower than 40 mg/dL.

It’s important to know that providers consider other factors in addition to your cholesterol numbers when they make treatment decisions.

What is dyslipidemia vs. hyperlipidemia?

They’re mostly interchangeable terms for abnormalities in cholesterol. Your cholesterol can be “dysfunctional” (cholesterol particles that are very inflammatory or an abnormal balance between bad and good cholesterol levels) without being high.

Both a high level of cholesterol and increased inflammation in “normal” cholesterol levels put you at increased risk for heart disease. Your providers may use both terms to refer to a problem with your cholesterol levels, and both mean that you should do something to bring the levels down.

What is Hyperlipidemia vs. Hypercholesterolemia

If you have hyperlipidemia, you have high lipid levels – including triglycerides and LDL – in your blood.

Another type of cholesterol problem is called hypercholesterolemia. That means only your LDL levels are too high.

What is mixed hyperlipidemia?

When you have this, you have high triglycerides and LDL, as well as low HDL. It's an inherited condition, part of a group called "familial hyperlipidemia." It's the most common type found among young people who have had heart attacks.

Familial hypercholesterolemia is a genetic condition that causes high LDL only. Another inherited condition that affects your cholesterol is familial hypertriglyceridemia. When you have this, your body produces too much VLDL. As a result, your VLDL and triglyceride levels will be high.

How common is hyperlipidemia?

Hyperlipidemia is very common. Ninety-three million American adults (age 20 and older) have a total cholesterol count above the recommended limit of 200 mg/dL.

How serious is high cholesterol?

Hyperlipidemia can be very serious if it’s not managed. As long as high cholesterol is untreated, you’re letting plaque accumulate inside of your blood vessels. This can lead to a heart attack or stroke because your blood has a hard time getting through your blood vessels. This deprives your brain and heart of the nutrients and oxygen they need to function.

Cardiovascular disease is the leading cause of death in Americans.

How does hyperlipidemia (high cholesterol) affect my body?

Hyperlipidemia (high cholesterol) that’s not treated can allow plaque to collect inside of your body’s blood vessels (atherosclerosis).

This can bring on hyperlipidemia complications that include:

Heart attack.

Stroke.

Coronary artery disease.

Carotid artery disease.

Sudden cardiac arrest.

Peripheral artery disease.

Microvascular disease.

Signs and Symptoms

Most people with hyperlipidemia can't tell that they have it at first. A blood test is the only way to find out if you have it. It's not something you can feel, but you may notice the effects of it someday.

Cholesterol, along with triglycerides and other fats, can build up inside your arteries. This makes the blood vessels narrower and makes it more difficult for blood to get through. Your blood pressure could go up. The narrowing of your arteries could cause several problems:

Coronary artery disease

Coronary artery disease (CAD) is the most common form of heart disease in the U.S. When your arteries get clogged, it becomes harder for your heart to get the blood it needs to work correctly. That can lead to a heart attack or heart failure. You may not realize it's happening until you have chest pain (also called angina) or some other symptoms of a heart attack.

Heart attack

The stuff clogging up your arteries (called plaques) can break off, creating a blood clot. The clot might block the flow of blood in your artery right there, or it might break free and travel down an artery, creating a blockage farther along. If the blockage causes part of your heart to stop getting blood flow, you're having a heart attack.

Symptoms of a heart attack include:

Chest pain

Pain that spreads to your jaw, shoulder, arm, back, or neck

Cold sweat

Indigestion or nausea

Shortness of breath

Dizziness

Fatigue

Women may have a sharp pain in the back, neck, or arm.

Stroke

When you have a stroke, a clot travels through your body and blocks blood flow to part of your brain. Symptoms of a stroke include:

Headache that comes on suddenly and is severe

Trouble speaking – slurred words, or not being able to speak. You might also have trouble understanding what people are saying.

Numbness or weakness. This may affect just one side of your body. One side of your mouth may droop when you try to smile.

Vision problems. You eyesight might be blurred in one or both eyes.

Balance issues. You might have trouble walking.

Fatty growths

If you have inherited hyperlipidemia, you might see yellow, fatty deposits under your skin. These are places where cholesterol has built up. If they're around your eyelids next to your nose, they're called xanthelasmas.

These deposits also can show up other places on your body, and when they do, they're called xanthomas. The most common places to get them are your elbows, knees, other joints, hands, feet, and butt.

Causes

What causes cholesterol to get high?

Various hyperlipidemia causes include:

Smoking.

Drinking a lot of alcohol.

Eating foods that have a lot of saturated fats or trans fats.

Sitting too much instead of being active.

Being stressed.

Inheriting genes that make your cholesterol levels unhealthy.

Medications that are helpful for some problems can make your cholesterol levels fluctuate, such as:

Beta-blockers.

Diuretics.

Hormonal birth control.

Steroids.

Antiretrovirals for HIV.

Medical problems can also affect how much cholesterol you have.

These include:

Being overweight or obesity.

Liver disease.

Pancreas disease.

Multiple myeloma.

Polycystic ovary syndrome (PCOS).

Hypothyroidism.

Primary biliary cholangitis.

Chronic kidney disease.

Diabetes.

Lupus.

Sleep apnea.

HIV.

What are the risk factors for hyperlipidemia?

Several things can put you at a higher risk of hyperlipidemia, including:

Having a family history of high cholesterol.

Having hypothyroidism.

Having obesity.

Not eating a nutritious diet.

Drinking too much alcohol.

Having diabetes.

Smoking.

Diagnosis and Tests

How is hyperlipidemia (high cholesterol) diagnosed?

Your provider will want:

A physical exam.

Your medical history.

Laboratory testing of your cholesterol levels in your blood.

Your family’s medical history.

To calculate your 10-year Atherosclerotic Cardiovascular Disease (ASCVD) Risk Score.

A blood test called a lipid panel will tell you these numbers:

Type of cholesterol	Best number to have
Total cholesterol	Less than 200 mg/dL
Bad (LDL) cholesterol	Less than 100 mg/dL
Good (HDL) cholesterol	At least 60 mg/dL
Triglycerides	Less than 150 mg/dL

What’s considered high cholesterol?

Anything higher than 200 mg/dL is high cholesterol.

Total cholesterol	Rank
Less than 200 mg/dL	Best
200 mg/dL to 239 mg/dL	Borderline high
240 mg/dL and higher	High

What tests will be done to diagnose hyperlipidemia?

Your provider may also do these tests:

High sensitivity C-reactive protein (hs-CRP).

Lipoprotein (a).

Apolipoprotein B.

Coronary calcium scan.

Sometimes, tests are appropriate for children and adolescents. The CDC points out that 1 in 5 adolescents have high cholesterol in the United States.

Check with your doctor about a cholesterol test for your child if:

your family has a history of early heart attacks or heart disease

your child has excess weight or obesity

your child has diabetes

Management and Treatment

How is hyperlipidemia (high cholesterol) treated?

Lifestyle changes that can lower your cholesterol include a healthy diet, weight loss, and exercise.

You should:

Choose foods low in trans fats and saturated fats. One way to do this is to substitute oils such as olive, sunflower, safflower, and canola for other fats in cooking.

Eat more fiber-rich foods, such as oatmeal, apples, bananas, pears, prunes, kidney beans, chickpeas, lentils, and lima beans. Soluble fiber reduces your LDL cholesterol.

Have fish twice a week. Fatty fish (tuna, salmon, mackerel, herring, trout) contains omega-3 fatty acids, which lower your triglycerides. You also can get omega-3 from walnuts, flaxseed, and canola oil.

Avoid sugary drinks and added sugars.

Avoid fried and processed meats.

If you smoke, quit. When you stop smoking, your HDL (good cholesterol) levels go up. Experts say to quit smoking, you should focus on your motivation for quitting, get support, maintain your confidence level, and learn from past attempts. You can talk to your doctor about medications that can help.

Sleep at least 7 hours each night. Poor sleep has been linked to high blood pressure and heart disease.

Manage your stress level. High stress is linked to inflammation in your body, which can raise your blood pressure and lower your HDL levels. Ways to reduce stress include meditation, journaling, yoga, exercise, and counseling.

Limit your alcohol, too. That means no more than one drink a day.

Step up your exercise habits. Aim for about 30 minutes of moderate-intensity activity, like a brisk walk, most days of the week. You don't have to do it all at once. Even 10 to 15 minutes at a time can make a difference.

What medications are used for hyperlipidemia?

If lifestyle changes aren’t enough to treat your hyperlipidemia, your doctor may prescribe medication.

Statins are the first line medication for hyperlipidemia. If you cannot tolerate statins or if they do not reduce your LDL cholesterol enough, mRNA and monoclonal antibody drugs have been developed recently.

Statins: Drugs that prevent your liver from making cholesterol are known as statins. They're a popular choice to lower the amount of cholesterol in your blood. But in some people, statins cause serious side effects, including muscle pain, mental confusion, and digestion problems. In rare cases, they can cause liver damage. Talk to your doctor about weighing the benefits versus the side effects, if you have any. Don't just stop your medication.

atorvastatin (Lipitor)

fluvastatin (Lescol XL)

lovastatin (Altoprev)

pitavastatin (Livalo)

pravastatin (Pravachol)

rosuvastatin (Crestor)

simvastatin (Zocor)

Cholesterol absorption inhibitors: These are a newer type of drug that blocks cholesterol that you've eaten from being taken into your body by your intestine. They work in combination with statins. An example is the drug ezetimibe (Zetia/Nexlizet).

PCSK9 inhibitors: These are also a new class of drugs. They lower LDL, or “bad,” cholesterol. PCSK9 is a protein in your liver that can increase your cholesterol level. These drugs work by blocking the receptors of the protein, which allows your liver to clear away more cholesterol. Right now, there are two FDA-approved medications: alirocumab (Praluent) and evolocumab (Repatha). Studies show that PCSK9 inhibitors can actually prevent heart attacks or strokes.

Nicotinic acid: This also affects how your liver makes fats. It lowers your LDL cholesterol and triglycerides and raises your HDL cholesterol.

Bile-acid binding resins: These medications trick your body into using up cholesterol. They bind to bile, an acid involved in digestion, so it can't do its job. Your liver has to make more bile, and for that, it needs cholesterol. That leaves less cholesterol in your bloodstream.

cholestyramine (Prevalite)

colesevelam (Welchol)

colestipol (Colestid)

Fibrates: The drugs fenofibrate (Tricor, Fenoglide, Triglide) and gemfibrozil (Lopid) lower the amount of very low density cholesterol (VLDL) your body makes and helps your body remove triglycerides from your blood. If you take it with a statin, that increases the risk of statin side effects.

Niacin: (Niacor) This drug limits how much LDL and VLDL your liver can make. It's been linked to liver damage and strokes, so your doctor isn't likely to prescribe it unless you can't take statins.

Omega-3 supplements: Your doctor can prescribe these, or you can buy them over the counter. They can help lower triglycerides. But check with your doctor before you start taking them; they might interact with other medicines.

Other supplements: Many supplements are touted as good for treating high cholesterol. They include berberine, flaxseed, garlic, green tea, red yeast rice, C 15:0, and nattokinase. The evidence that these supplements work varies. If you want to try one, talk to your doctor about it first.

New medications for high cholesterol

Inclisiran

Inclisiran is a new drug using mRNA technology. It has been approved in Europe but not yet in the United States.

Clinical trials in 2020 showed the drug could cut levels of LDL cholesterol by 50 percent in people who are either intolerant or resistant to standard statin medications.

Inclisiran is the pioneer cholesterol drug in what’s called “small interfering RNA therapy.” This is a type of drug that blocks, or interferes with, the function of an RNA messenger (mRNA). An mRNA is a molecule that carries code for making a particular protein.

In the case of Inclisiran, the drug blocks, or interferes with, the production of an enzyme called PCSK9 (proprotein convertase subtilisin kexin type 9). This enzyme causes problems with the LDL receptors in the liver that are necessary for the uptake of LDL cholesterol by liver cells.

By blocking PCSK9 activity, Inclisiran helps the body reduce the amount of LDL cholesterol. The drug is intended for hyperlipidemia treatment in adults whose high LDL cholesterol persists even while they’re on a maximum tolerated dose of statin therapy.

Bempedoic acid (Nexlitol) and ezetimibe (Nexlizet)

The two drugs Nexlitol and Nexlizet, approved by the FDA in 2020, are the first new non-statin cholesterol drugs approved by the FDA since 2002.

Nexlitol contains bempedoic acid, which has been shown in clinical trials to inhibit cholesterol. It’s designed to be taken in combination with the maximum tolerable dosage of statins.

Nexlizet contains ezetimibe, which lowers cholesterol by preventing the body from absorbing cholesterol from foods. It’s also designed to be taken along with statins.

Both Nexlitol and Nexlizet can cause serious side effects. Your doctor can help you decide if one of these drugs would benefit your treatment plan.

Alirocumab (Praluent)

Praluent (alirocumab) was approved by the FDA in 2021 as an add-on treatment for familial hypercholesterolemia. This is a genetic condition that causes severely high cholesterol.

Praluent was originally approved by the FDA in 2015 for treating heart disease and primary inherited hyperlipidemia. It was then the first PCSK9 inhibitor approved by the FDA.

PCSK9 inhibitor drugs work by attaching to the PCSK9 gene to prevent it from degrading LDL receptors in the liver that help lower LDL cholesterol in the body. This differs from the new mRNA drug Inclirisan, in that inhibitors attach to the PCSK9 gene, whereas the mRNA drug prevents PCSK9 from being produced.

Alirocumab, the active drug in Praluent, is a monoclonal antibody. This is a protein synthesized in a laboratory that behaves like antibodies made by the human body.

Praluent comes as a liquid solution in a prefilled pen. You deliver it as an injection every 2 to 4 weeks, which can be done at home. It has a number of reported possible side effects, so be sure to discuss with your doctor whether it would suit your treatment plan.

Because hyperlipidemia affects so many people. researchers continue to look for new ways to treat it. One new drug, called inclisiran, works by interfering with your body's production of PCSK9, rather than just blocking reception of it.

If your doctor prescribes a drug to control your cholesterol, you'll likely have to take it long-term to keep your levels in check.
Are there side effects of hyperlipidemia (high cholesterol) treatment?

Any medication can have side effects, but the benefits of statins far outweigh the risks of minor side effects. Let your provider know if you aren’t doing well on your medicine so they can develop a plan to manage your symptoms.

How soon will the hyperlipidemia (high cholesterol) treatment start working?

Your provider will order another blood test about two or three months after you start taking hyperlipidemia medication. The test results will show if your cholesterol levels have improved, which means the medicine and/or lifestyle changes are working. The risk of cholesterol causing damage to your body is a long-term risk, and people usually take cholesterol-lowering treatments for a long time.

Prevention

How can I reduce my risk of hyperlipidemia?

Even children can get their blood checked for high cholesterol, especially if someone in the child’s family had a heart attack, stroke or high cholesterol. Children and young adults can get checked every five years.

Once you reach middle age, you should have your cholesterol checked every year or two. Your healthcare provider can help you decide how often you should have a hyperlipidemia screening.

How can I prevent hyperlipidemia (high cholesterol)?

Changes you make in your life can keep you from getting hyperlipidemia.

Things you can do include:

Stop smoking.

Stay active instead of sitting too much.

Keep your stress level down.

Get the right amount of sleep.

Eat healthy foods.

Cut back on eating fatty meats.

Don’t buy snacks that have “trans fat” on the label.

Stay at a healthy weight.

Prognosis

What can I expect if I have hyperlipidemia?

If you have hyperlipidemia, you’ll need to keep using healthy lifestyle habits for years to come. You’ll also need to keep follow-up appointments with your provider and continue to take your medicine. If you and your provider are able to manage your cholesterol level, you may not have serious health problems as a result of it.

How long will you have hyperlipidemia?

Hyperlipidemia is a condition you’ll need to manage for the rest of your life.

What is the outlook for hyperlipidemia (high cholesterol)?

Although high cholesterol puts you at risk for heart attacks and stroke, you can protect yourself by living a healthier lifestyle and taking medicine if needed.

Living With

How do I take care of myself with hyperlipidemia?

Be sure to follow your provider’s instructions for making your lifestyle healthier.

Here are things you can do yourself:

Exercise.

Stop smoking.

Sleep at least seven hours each night.

Manage your stress level.

Eat healthier foods.

Limit how much alcohol you drink.

Stay at a healthy weight.

Other things you can do:

If your provider ordered medicine for you, be sure to keep taking it as the label tells you to do.

Talk to your provider about estimating your risk of heart disease and stroke so they can manage your risk effectively.

Keep your follow-up appointments.

When should I see my healthcare provider?

You should see your provider if you have:

High blood sugar.

High blood pressure.

High cholesterol.

When should I go to the ER?

Call 911 if you think you’re having a heart attack or stroke.

What questions should I ask my doctor?

Do I need to make lifestyle changes, take medication or both?

If I do what you tell me to do, how quickly can my numbers improve?

How often do I need to check in with you?

One Final Note..

Hyperlipidemia, or high cholesterol, can let plaque collect inside of your blood vessels and put you at risk of a heart attack or stroke. The good news is that you have the power to reduce your risk of heart attack and stroke. Exercising more and eating healthier are just two of the ways you can improve your cholesterol numbers. Taking medicine your provider orders makes a difference, too.

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