What is Hyperlipidemia (High Cholesterol)?
Hyperlipidemia is a condition that includes various inherited and developed disorders, resulting in high levels of fats in the body. It’s quite common, particularly in Western countries but also globally. In more technical terms, it’s when LDL (bad cholesterol), total cholesterol, and other fat-related elements are at higher levels than 90% of the population, or when HDL (good cholesterol) levels are lower than 10% of the population. This term ‘lipids’ generally includes different types of cholesterol and fats.
Many research studies have shown that high levels of LDL cholesterol can increase the risk of developing blocks in blood vessels. On the other hand, HDL cholesterol helps to control cholesterol levels to prevent imbalances that can increase the risk of blocked vessels. Each individual’s ideal LDL cholesterol level is determined by their overall risk for heart diseases, and treatment should be adjusted to suit the individual. The process of managing risk factors like hyperlipidemia to lower the risk of heart disease is known as ‘primary prevention.’ Information gathered from a wide range of studies shows a clear correlation between high LDL cholesterol levels, heart-related events, and death rates.
The way we treat hyperlipidemia is continually developing as we gain a better understanding of the issue’s root cause while also building upon previous treatment methods. We will provide an overview of the background, how to diagnose, and the most updated treatment guidelines for hyperlipidemia in this article.
What Causes Hyperlipidemia (High Cholesterol)?
Hyperlipidemia, or high levels of fat in the blood, can come in two main types: primary or secondary. Primary hyperlipidemia is inherited and derived from numerous genetic disorders that a person can get from birth. On the other hand, secondary hyperlipidemia is typically acquired from various causes like unhealthy diet, certain medications like amiodarone and glucocorticoids, underactive thyroid, uncontrolled diabetes, and unhealthy lifestyle choices.
Family history often plays an important role in lipid metabolism disorders. For instance, in a certain study, around 54% of patients with early onset coronary artery disease had a hereditary disorder. In most of these patients, hyperlipidemia followed a polygenic inheritance pattern and risk factors like obesity, high intake of saturated fat, and high cholesterol in diet influenced the disease manifestations. Some unconventional risk factors might also play a part.
Cholesterol, which is a fatty substance circulating in the blood, plays a big role in the process of atherosclerosis, or hardening of arteries. It comes from two main sources: some portions (300-700 mg per day) come from eating too much dietary fat, particularly from animals, while a larger portion (800-1200 mg per day) is directly produced by the body, especially the liver. In addition to excessive eating of animal fats, other common causes of high cholesterol and/or increase in triglycerides can be diabetes, chronic kidney disease, kidney disease with excessive protein in urine, underactive thyroid, age, and lack of physical activity. Certain medications like thiazide diuretics, beta-blockers, birth control pills, and antiretroviral drugs can also lead to high cholesterol.
Dyslipidaemias, or high levels of lipids in the blood due to genetic abnormalities, which are more uncommon, account for approximately 60% of the changes in blood lipid levels and are frequently responsible for causing heart diseases at an early age.
Risk Factors and Frequency for Hyperlipidemia (High Cholesterol)
Hyperlipidemia, a condition where there are too many lipids or fats in the blood, affects over three million adults in the U.S. and Europe. This number is rapidly increasing. Often a long-term, worsening disease, it requires lifestyle and dietary changes, and sometimes additional medications to lower lipids. It’s most severe in patients with early-onset coronary artery disease (CAD). For males, this is CAD that occurs before age 55 to 60 and for females, before age 65. In these cases, around 75-85% of individuals have hyperlipidemia, which is much higher than the 40-48% seen in people of a similar age who don’t have CAD.
It’s estimated that over half of American adults have high LDL (bad cholesterol levels). However, less than 35% of those effectively manage their high LDL. This shows the disease is not being adequately treated. According to the JAMA Network, the disease is more prevalent among whites than blacks, and among men than women across all ethnic groups. Countries with lower levels of obesity and less saturated fat consumption have a lower rate of hyperlipidemia and CAD compared to Europe and the U.S.
Children under the age of two can develop hyperlipidemia too, especially if they are underweight or obese.
Signs and Symptoms of Hyperlipidemia (High Cholesterol)
People with high cholesterol often don’t show symptoms, so it’s very important for doctors to take a detailed patient history. This includes asking about family history related to heart disease, high cholesterol, and inherited high cholesterol; their diet and exercise habits; their use of tobacco, alcohol, or drugs; any heart disease they may have; risk factors or history of heart disease; and any signs of peripheral artery disease or chest pain.
Along with asking about the patient’s medical history, a thorough physical examination is also crucial. This includes accurately measuring blood pressure, looking for skin changes that could indicate high cholesterol, listening for abnormal sounds in the carotid artery in the neck and the femoral artery in the groin that could suggest narrowing of the arteries, listening for an extra heart sound, and checking the strength of the pulses in all four limbs. All these quick and easy checks can help diagnose high cholesterol.
- Deep family history of heart disease and high cholesterol
- Diet and exercise habits
- Tobacco, alcohol, or drug use
- Presence of heart disease
- Risk factors or history of heart disease
- Symptoms of peripheral artery disease or chest pain
- Blood pressure measurement
- Skin examination for changes indicating high cholesterol
- Listening for abnormal arterial sounds
- Listening for an extra heart sound
- Checking pulse in all four limbs
Testing for Hyperlipidemia (High Cholesterol)
Several experts have put together guidelines for lipid screening, a procedure used to measure cholesterol and triglyceride levels in the blood. These guidelines offer varying advice about when doctors should start checking for high blood lipids – a condition called hyperlipidemia – and how often these checks should be done. Generally, it is recommended that men be tested once they reach 35 years old if there are no other risk factors for heart disease. However, if they have other risk factors, they should start testing at 25 years old. Women can wait until they are 45 years old, unless they have other risk factors, in which case they’d start at 30 to 35 years old. Screening tests should then be done every five years for lower-risk patients. People at higher risk may need them more frequently.
The most useful test to have is a fasting lipid profile, which includes LDL, HDL, triglycerides, and total cholesterol levels. There’s also the option to add some extra checks, for what’s known as a more comprehensive test. It’s important not to eat or drink anything except water for 9 to 12 hours before the test to keep the results accurate.
Before starting a prescription for high LDL levels with a drug called a statin, it’s important to have a liver function test. This is to make sure you don’t already have a liver problem which could be made worse by the statin medication. It’s also important to perform a Hgb A1c level check to screen for diabetes. Other checks include blood pressure tests (for problems like hypertension), TSH (to rule out thyroid issues), and a simple urine test to check for albuminuria. All these tests are important in order to understand the risks and benefits of starting treatment for high blood lipids.
Treatment Options for Hyperlipidemia (High Cholesterol)
The decision to treat high levels of LDL cholesterol, the ‘bad’ cholesterol, will be determined by your doctor after considering your overall risk of heart disease. This decision should be thoroughly discussed. Normally, we get less risk reduction from treating high cholesterol for people without evident heart disease than for those who already have it. When there is no definite heart disease diagnosis, only treating high LDL cholesterol has been found beneficial. There’s no known benefit to treating high levels of triglycerides or low levels of ‘good’ cholesterol – HDL.
For starters, the focus is on diet and lifestyle changes, and possibly cholesterol-lowering medicines if needed. If you have mild high cholesterol and your risk of heart disease in the next decade is below 7.5%, you should concentrate on having a low-fat and low-carb diet, and exercising regularly – ideally 30 minutes a day, 5 to 6 days a week. Experts from the American Heart Association also recommend limiting your intake of saturated fats to about 5% of your daily calories, and avoiding trans fats as much as possible. Quitting smoking, managing blood pressure, and losing excessive weight can also help reduce your risk of vascular disease. If you’re at a moderate to high risk of heart disease (over 7.5%), you should consider taking cholesterol-lowering ‘statin’ drugs too.
Scientific studies have shown that lowering LDL cholesterol can reduce chances of heart problems, particularly lowering the risk of heart attacks. Statin therapy can be beneficial for most patients, from low to high risk. If it weren’t for side effects and cost restrictions, these medications would be prescribed to almost everybody. Therefore, the effects and cost of statin medications should be balanced against each individual’s potential benefit.
Here are some key recommendations:
– High-risk individuals should receive statin therapy for prevention, unless otherwise contraindicated.
– Drugs like Niacin, fibrates, and omega-3 fatty acids are not recommended for routine use in heart disease prevention.
– For patients who can’t tolerate high-intensity statin therapy, consider combining a moderate-intensity statin with another drug, ezetimibe.
– Moderate intensity statins include: lovastatin 40 mg, pravastatin 40 mg, simvastatin 40 mg, atorvastatin 10 to 20 mg, and rosuvastatin 5 to 10 mg.
– High-intensity statins include: atorvastatin 40 to 80 mg, rosuvastatin 20 to 40 mg.
If your doctor prescribes statin therapy, the total decrease in heart disease risk is generally around 20-30%. Regular follow-up is important when starting statin therapy. The bulk of the benefits come from a moderate dose, with a much smaller contribution from high-intensity therapy. Even so, high-intensity therapy can still be important and should be considered for all high-risk patients.
In case of an allergic reaction or intolerance to a statin, the doctor may decrease the dose or switch to a different cholesterol-lowering drug. When compared to ezetimibe, another cholesterol-lowering drug, evolocumab (a PCSK9 inhibitor) demonstrated greater reductions in LDL cholesterol levels in a 24-week trial. However, both of these medications can be considered as secondary options for treatment.
What else can Hyperlipidemia (High Cholesterol) be?
When doctors are trying to diagnose high cholesterol (hyperlipidemia), they should consider a list of other possible conditions as well. These conditions fall into two categories:
- Primary disorders: These are inherited conditions from the patient’s family, such as familial hypercholesterolemia, familial combined hyperlipidemia, dysbetalipoproteinemia, familial defective apolipoprotein B-100, and PCSK9 gain of function mutations, which can lead to high cholesterol.
- Secondary disease processes: These are conditions that don’t directly cause high cholesterol, but because they affect the body’s metabolism, they can indirectly lead to high cholesterol. Examples include liver disease or biliary obstruction (blockage of bile ducts), hypothyroidism (low thyroid hormone levels), nephrotic syndrome and chronic renal insufficiency (kidney problems), anorexia, obesity, metabolic syndrome, and diabetes.
Because these conditions have similar symptoms to high cholesterol, doctors need to take a full patient history and conduct several tests to determine the correct diagnosis.
What to expect with Hyperlipidemia (High Cholesterol)
Hyperlipidemia, or abnormally high levels of fat in the blood, is a condition that often lasts a lifetime, but can be controlled and managed effectively. If not treated, however, it can worsen and lead to fatal vascular diseases.
Continuous exposure to high lipid levels in the blood during early adulthood can gradually increase the risk of heart disease.
Adults who consistently have moderately or severely elevated levels of non-HDL cholesterol in their bodies also have a higher risk of developing heart disease. Aggressive medical treatments, including high-strength statin therapy, along with changes to diet and lifestyle, can be greatly beneficial.
According to a 20-year follow-up of the West of Scotland Coronary Prevention Study, patients who took statins for five years had better survival rates. They also had noticeable reductions in cardiovascular disease over twenty years. This evidence supports other studies showing that the use of statins can significantly reduce the risk of heart-related diseases when used correctly in a proactive treatment approach.
Possible Complications When Diagnosed with Hyperlipidemia (High Cholesterol)
Untreated or poorly managed high cholesterol can lead to several serious health issues, which might be life-threatening in the long term. These illnesses can range from artery diseases affecting the heart or limbs, strokes, aneurysms, type II diabetes, hypertension, to even the risk of death.
On the other hand, medications used to treat high cholesterol, like statins, aren’t free of side effects. Those might involve muscle disorders, kidney damage, joint pain, pains in the limb, feeling sick, muscle pain, liver damage, diarrhea, and a severe condition involving the breakdown of muscle tissue called rhabdomyolysis. It’s worth mentioning that from 5 to 20% of people taking statins might experience muscle-related problems. If any side effects appear, it might be necessary to reduce the dose, or switch to another cholesterol-lowering medicine like ezetimibe or evolocumab.
Common issues resulting from untreated or poorly treated high cholesterol:
- Heart vessel disease
- Peripheral artery disease
- Strokes
- Aneurysms
- Type II Diabetes
- High Blood Pressure
- Potential risk of death
Common side effects from cholesterol-lowering medications (Statins):
- Muscle disorders
- Kidney injury
- Joint pain
- Pains in the limb
- Feeling of sickness (nausea)
- Muscle pain
- Liver damage
- Diarrhea
- Rhabdomyolysis
Recovery from Hyperlipidemia (High Cholesterol)
Doing aerobic exercise, like jogging or cycling, can help to increase levels of HDL-cholesterol protein in your body. This protein plays a critical role in keeping your arteries and tissues healthy – it carries cholesterol away from them and takes it to the liver. Plus, it has antioxidants and anti-inflammatory properties that cause the release of nitric oxide, a compound that helps blood vessels to widen and improve blood flow. Just adding 10 more minutes of physical activity to your daily exercise can increase HDL levels by 1.4 mg/dl. On average, a good training program can boost your HDL cholesterol by 4.6%.
A mix of aerobic and anaerobic exercises (like weight lifting or sprinting), can also have a positive impact on your blood lipid levels. Spending about an hour every week on resistance training, a type of anaerobic activity, can make your lipid profile healthier. It’s important to stick to this recommendation to avoid overexertion while keeping your health in check.
Preventing Hyperlipidemia (High Cholesterol)
People diagnosed with hyperlipidemia, or high cholesterol levels, need to understand how the condition can harm their organs and what health risks it could lead to. It’s important to talk about adopting a healthier diet, quitting smoking, and making positive changes to lifestyle habits. If it’s necessary to take medication, the possible risks and benefits of each drug should be discussed before starting treatment.
Both the primary care doctor and the pharmacist are responsible for explaining the importance of taking medication regularly, any potential side effects, possible interactions with other drugs, and the overall pros and cons of the prescribed medications. They must also help the patient understand the risks tied to not taking the medication, and discuss any other potential treatment options they might have.
