Hypercholesterolaemia (High Cholesterol)
What is cholesterol?
Cholesterol is a waxy, fat-like substance that is found naturally in your body. It is essential for many of the bodies normal functions. Your liver makes most of the cholesterol you need, but cholesterol is also obtained from certain foods.
Having too much cholesterol in your blood can increase your risk of developing heart and circulatory disease.
What is hypercholesterolaemia?
Hypercholesterolaemia simply means that the level of cholesterol in your blood is higher than recommended.
The main concern is a type of cholesterol called LDL cholesterol (Low-Density Lipoprotein), often referred to as "bad cholesterol."
When LDL cholesterol is too high, it can gradually build up inside the walls of your arteries, forming fatty deposits called atherosclerotic plaques.
Over many years these plaques can narrow or block arteries, increasing the risk of:
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Heart attack
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Stroke
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Angina
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Peripheral arterial disease
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Kidney disease
Understanding the different types of cholesterol
LDL Cholesterol ("Bad Cholesterol")
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Carries cholesterol from the liver to the body.
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High levels increase cardiovascular risk.
HDL Cholesterol ("Good Cholesterol")
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Helps remove excess cholesterol from arteries.
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Higher levels are generally protective.
Triglycerides
These are another type of fat in the bloodstream.
Raised triglycerides may increase cardiovascular risk and are commonly associated with:
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Diabetes
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Obesity
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Excess alcohol
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Poor diet
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Lack of exercise
What causes high cholesterol?
Several factors contribute.
Lifestyle factors
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Diet high in saturated fats
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Excess body weight
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Physical inactivity
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Smoking
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Excess alcohol intake
Medical conditions
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Diabetes
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Underactive thyroid
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Kidney disease
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Liver disease
Family history
Some people inherit a condition called Familial Hypercholesterolaemia (FH), where cholesterol levels are very high from birth.
People with FH have a much greater lifetime risk of developing heart disease unless treated early.
Does high cholesterol cause symptoms?
Usually no.
Most people feel completely well.
High cholesterol is often discovered only after:
• A routine blood test
• A heart attack
• A stroke
• Cardiovascular assessment
This is why cholesterol testing is so important.
How is cholesterol measured?
A blood test called lipid profile measures
• Total cholesterol
• LDL cholesterol
• HDL cholesterol
• Triglycerides
• Sometimes non-HDL cholesterol
• Occasionally Apolipoprotein B (ApoB) and Lipoprotein(a) [Lp(a)] may be measured in selected patients
Your doctor will also consider
• Age
• Blood pressure
• Diabetes
• Smoking
• Family history
• Previous heart disease
Together these determine your overall cardiovascular risk.
Cholesterol targets
Targets vary depending on your individual risk.
Your doctor will advise which target is appropriate for you.
Risk Level LDL Target
Low Risk Less than 3.0 mmol/L
Moderate Risk Less than 2.6 mmol/L
High Risk Less than 1.8 mmol/L
Very High Risk (previous heart attack or stroke) Less than 1.4 mmol/L
Extremely High Risk (recurrent events) Less than 1.0 mmol/L may be considered
How can I lower my cholesterol?
Eat a heart-healthy diet
Aim to:
✔ Eat more vegetables
✔ Eat fruit every day
✔ Choose wholegrains
✔ Eat beans and pulses
✔ Eat oily fish once or twice each week
✔ Choose olive oil for cooking
✔ Eat unsalted nuts in moderation
Reduce
• Butter
• Cheese
• Cream
• Processed meat
• Cakes
• Pastries
• Fried foods
• Fast food
Increase fibre
Soluble fibre helps remove cholesterol from the body.
Good sources include:
• Oats
• Barley
• Beans
• Lentils
• Apples
• Pears
Plant sterols
Foods containing plant sterols can reduce LDL cholesterol by around 7–10%.
Examples include fortified yoghurts and spreads.
Exercise regularly
Aim for:
• At least 150 minutes of moderate exercise each week
Examples include:
• Brisk walking
• Cycling
• Swimming
• Dancing
• Gardening
Even small increases in activity improve heart health.
Maintain a healthy weight
Losing even 5–10% of body weight can improve cholesterol, blood pressure and diabetes risk.
Stop smoking
Stopping smoking rapidly reduces cardiovascular risk regardless of cholesterol level.
Limit alcohol
Drink within recommended limits.
If your triglycerides are high, reducing alcohol can make a significant difference.
Medicines used to lower cholesterol
Lifestyle changes are important but many people also benefit from medication.
Statins
Statins are the first-line treatment.
Examples include:
• Atorvastatin
• Rosuvastatin
• Simvastatin
They work by reducing cholesterol production in the liver.
Statins typically lower LDL cholesterol by 30–60%, depending on the dose.
Most people have no side effects, however occasionally people experience:
• Muscle aches
• Mild stomach upset
• Headache
Serious side effects are uncommon, however your doctor will monitor you liver function tests on a regular
basis as on rare occasions statins can affect the function of the liver.
Ezetimibe
Ezetimibe reduces cholesterol absorption from the intestine.
It lowers LDL cholesterol by around 20% and is often combined with a statin.
PCSK9 inhibitors
These injectable medicines include:
• Evolocumab
• Alirocumab
They can lower LDL cholesterol by approximately 60% and are used for selected high-risk patients.
Inclisiran
Inclisiran is a newer injectable treatment that reduces cholesterol production in the liver.
It is given:
• Initial injection
• 3 months later
• Every 6 months thereafter
It produces substantial LDL reduction and improves treatment adherence because of its infrequent dosing.
Bempedoic acid
This tablet is useful for some patients who cannot tolerate statins or require additional cholesterol lowering.
Is treatment lifelong?
Usually, yes.
Stopping cholesterol medication often allows cholesterol levels to rise again.
Your treatment may be adjusted over time depending on:
• Cholesterol levels
• Age
• Side effects
• Overall cardiovascular risk
Familial hypercholesterolaemia (FH)
You may have FH if:
• LDL cholesterol is very high
• Several family members have high cholesterol
• A close relative developed heart disease at a young age
Family members may also require cholesterol testing.
Early diagnosis saves lives.
When should I seek medical advice?
Arrange medical review if you:
• Develop muscle pain after starting medication
• Experience medication side effects
• Have concerns about your cholesterol results
• Have a strong family history of early heart disease
Seek urgent medical attention immediately if you develop:
• Chest pain
• Sudden weakness
• Difficulty speaking
• Sudden loss of vision
• Severe shortness of breath
Frequently asked questions:
Can I lower cholesterol without tablets?
Some people can through diet, exercise and weight loss. However, many people—particularly those at higher cardiovascular risk or with inherited high cholesterol—also require medication.
Should I avoid eggs?
For most people, moderate egg consumption does not significantly affect blood cholesterol. Overall dietary pattern is more important than avoiding individual foods.
Can I reverse cholesterol build-up?
Aggressive LDL cholesterol reduction can slow plaque progression and, in some cases, lead to modest plaque regression. More importantly, it greatly reduces the risk of heart attack and stroke.
Are statins safe?
Yes. Statins are among the most extensively studied medicines in cardiovascular care and have been shown to substantially reduce the risk of heart attack, stroke and cardiovascular death.