Hypercholesterolemia

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Cholesterol and plaque

High blood cholesterol is a condition that causes the levels of certain bad fats, or lipids, to be too high in the blood. This condition is usually caused by lifestyle factors, such as diet, in combination with the genes that you inherit from your parents. Less commonly, it is caused by other medical conditions or some medicines.

You may be diagnosed with high blood cholesterol if you consistently have high levels of bad cholesterol in your blood in a routine test called a lipid panel. To treat high blood cholesterol, your doctor may recommend heart-healthy lifestyle changes, such as heart-healthy eating, quitting smoking, or aiming for a healthy weight. Your doctor may also prescribe medicines, such as statins, to lower and control your high blood cholesterol. Untreated high blood cholesterol can lead to the buildup of plaque in the blood vessels, called atherosclerosis. Plaque buildup increases your risk for heart attack, stroke, and peripheral artery disease.

Causes- High Blood Cholesterol

The most common cause of high blood cholesterol is an unhealthy lifestyle. However, the genes that you inherit from your parents, other medical conditions, and some medicines may also cause high blood cholesterol.

- High Blood Cholesterol

Unhealthy eating patterns, lack of physical activity, and smoking can cause high blood cholesterol.

  • Unhealthy eating patterns, such as consuming high amounts of saturated fats or trans fats, can increase bad low-density lipoprotein cholesterol (LDL cholesterol).
  • Lack of physical activity, such as spending a lot of time during the day sitting and watching TV or using the computer, is linked with lower levels of good high-density lipoprotein cholesterol (HDL cholesterol).
  • Smoking lowers HDL cholesterol, particularly in women, and increases LDL cholesterol.
Genes

Some people may develop high blood cholesterol because of mutations, or changes, in their genes. These mutations make it harder for the body to clear LDL cholesterol from the blood or break it down in the liver. Familial hypercholesterolemia is one inherited form of high blood cholesterol.

- Other medical conditions

The following medical conditions may cause high blood cholesterol:

  • Chronic kidney disease
  • Diabetes
  • HIVexternal link
  • Hypothyroidism
  • Overweight and obesity
  • Polycystic ovary syndrome
  • Inflammatory diseases such as psoriasis, lichen planus, pemphigus, histiocytosis, lupus erythematosus, and rheumatoid arthritis
- Medicines

Some medicines that you take for other medical conditions can increase your cholesterol. Examples of these medicines include the following:

  • Diuretics such as thiazide that are used for high blood pressure
  • Immunosuppressive drugs such as cyclosporine that are used to treat inflammatory diseases such as psoriasis or to prevent rejection after a transplant
  • Steroids such as prednisone that are used to treat inflammatory diseases such as lupus and psoriasis
  • Retinoids such as retinol that are used to treat acne
  • Antiretroviral medicines used to treat HIV
  • Antiarrhythmic medicines such as amiodarone that are used in treatment for irregular rhythm of the heart

You may have an increased risk for high blood cholesterol because of your age, your family history and genetics, and your race.

- Age

may have an increased risk for high blood cholesterol because of your age, your family history and genetics, and your race.

- Family history

Your body’s metabolism and chemistry change as you age. For example, your liver does not remove low-density lipoprotein (LDL) cholesterol as efficiently as when you were young. These normal age-related changes may increase your risk of developing high blood cholesterol.

- Race

Genetic studies have found that related family members tend to have similar levels of low-density lipoprotein (LDL) cholesterol, known as bad cholesterol, or high-density lipoprotein (HDL) cholesterol, known as good cholesterol. Depending on the genes in your family, you may have an increased risk for high blood cholesterol. Learn more about current research to better understand how genetic differences may affect how our bodies absorb cholesterol from the foods that we eat, how much cholesterol the liver produces and removes, and how we respond to high blood cholesterol treatments.

Screening and Prevention

Your doctors will order routine lipid panel blood tests to screen for high blood cholesterol. The timing and frequency of these blood tests will depend on your age and risk factors or family history for high blood cholesterol or other cardiovascular diseases such as heart attack or stroke. Learn about heart-healthy lifestyle changes that your doctor may recommend to help you prevent high blood cholesterol.

- Lipid panel to test for high blood cholesterol

Doctors use lipid panels to check whether you have healthy levels of cholesterol in your blood. A lipid panel will measure the total cholesterol, high-density lipoprotein(HDL) cholesterol, and non-high-density lipoprotein (non-HDL) cholesterol levels in your blood. Non-HDL cholesterol includes low-density lipoprotein (LDL) cholesterol and is calculated by subtracting your HDL cholesterol levels from your total cholesterol levels. See the table below to learn whether you have healthy blood cholesterol levels based on your age and sex.

When you receive this screening will depend on your age, risk factors, and family history of high blood cholesterol and cardiovascular diseases such as atherosclerosis, heart attack, or stroke.

  • Age 19 or younger. Screening begins at ages 9 to 11 and should be repeated every 5 years. Screening may be performed as early as age 2 if there is a family history of high blood cholesterol, heart attack, or stroke.
  • Age 20 or older. Younger adults should be screened every 5 years. Men ages 45 to 65 and women ages 55 to 65 should be screened every 1 to 2 years.

If your blood cholesterol levels are not within the healthy range for your age and sex, your doctor may also recommend heart-healthy lifestyle changes to help you lower or control your high blood cholesterol and order a repeat lipid profile test.

Did you know that cholesterol is an important part of many organs in our body and that high levels of bad types of cholesterol can increase your risk of cardiovascular disease?

Cholesterol is an important building block for our bodies. Cholesterol is produced by many organs in the body with major contributions from the liver and the brain. The body also gets some cholesterol from the diet, but this has a minor effect on blood cholesterol levels. Cholesterol is a major component of all cell membranes and is used to make essential molecules such as hormones, fat-soluble vitamins, and bile acids to help you digest your food.

You may also see a measurement for triglycerides on your lipid panel. Like cholesterol, triglycerides are a type of blood fat. Triglycerides form when you eat more calories than you need. They can supply energy to your muscles. When triglyceride levels are too high, they can put you at risk of a heart attack or stroke.

- Lifestyle

To prevent high blood cholesterol or if you have certain risk factors, your doctor may recommend that you adopt heart-healthy lifestyle changes, including eating healthy, being physically active, aiming for a healthy weight, quitting smoking, and managing stress.

Signs, Symptoms, and Complications- High Blood Cholesterol

High blood cholesterol does not cause specific symptoms. But people who have very high blood cholesterol may show signs such as xanthomas and corneal arcus. Undiagnosed or untreated high blood cholesterol can lead to serious complications such as heart attack and stroke.

- Complications Of High Blood Cholesterol

High blood cholesterol levels lead to atherosclerosis, or the buildup of plaque deposits in blood vessels throughout the body. Over time, chronic or uncontrolled high blood cholesterol can cause serious complications including the following:

  • Carotid artery disease
  • Coronary heart disease, including angina or heart attack
  • Peripheral artery disease
  • Stroke

Do you know why high blood cholesterol can cause these complications?

Cells are not able to destroy cholesterol, so they transfer excess cholesterol to the high-density lipoprotein (HDL) to transport it back to the liver for elimination. In this way, HDL protects your heart from atherosclerotic disease, so HDL cholesterol is sometimes called good cholesterol. Low-density lipoprotein (LDL) is a lipoprotein that carries 75 percent of the cholesterol in blood to the peripheral tissues. LDL is removed from the blood by the liver to be eliminated or reused. When the amount of LDL is too high, the liver is not able to remove all of it. It is deposited in the blood vessels, contributing to the development of atherosclerosis, so sometimes LDL cholesterol is called bad cholesterol.

Diagnosis- High Blood Cholesterol

Your doctor may diagnose you with high blood cholesterol based on your medical and family history, your physical exam, or whether you have consistently high low-density lipoprotein (LDL) cholesterol levels on repeat lipid panel blood tests. Your doctor may do more tests to see if other medical conditions may be causing high blood cholesterol.

Doctors use lipid panel tests to diagnose high blood cholesterol. A lipid panel will measure the total cholesterol, good high-density lipoprotein (HDL) cholesterol, and non-high-density lipoproteins (non-HDL) cholesterol levels in your blood. Non-HDL cholesterol includes LDL cholesterol and is calculated by subtracting your HDL cholesterol levels from your total cholesterol levels.

Your doctor may diagnose you with high blood cholesterol if your total or non-HDL level, which includes LDL cholesterol, is higher than what is considered to be healthy for your age, sex, and health status.

- Medical History

Your doctor will ask about your eating and physical activity habits, family history, and other risk factors for high blood cholesterol, heart attack, or stroke. Your doctor may ask whether you have any other signs or symptoms. This information can help your doctor determine whether you have complications or other conditions that may be causing you to have high blood cholesterol.

- Physical Exam

During your physical exam, your doctor will check for signs of very high blood cholesterol, such as xanthomas, or signs of other diseases that can cause high blood cholesterol.

- Tests

Your doctor may order some of the following tests for other medical conditions that may be causing your high blood cholesterol:

  • Blood tests to check your thyroid hormone levels can help rule out hypothyroidism as a cause of high blood levels of cholesterol or other fats, such as triglycerides. Total testosterone and dehydroepiandrosterone sulphate tests can help rule out polycystic ovary syndrome (PCOS).
  • Pelvic ultrasound to examine the ovaries and detect cysts. This can help rule out PCOS, which can affect cholesterol levels.
  • Skin biopsy to help rule out inflammatory diseases, such as psoriasis, which can affect cholesterol levels.

Treatment- High Blood Cholesterol

High blood cholesterol is treated with heart-healthy lifestyle changes and medicines to control or lower your high blood cholesterol. Lipoprotein apheresis is a procedure that can be used to treat familial hypercholesterolemia.

- Lifestyle changes

To help you lower or control your high blood cholesterol, your doctor may recommend that you adopt the following lifelong heart-healthy lifestyle changes:

  • Heart-healthy eating. As recommended in the 2015–2020 Dietary Guidelines for Americansexternal link, heart-healthy eating includes limiting the amount of saturated and trans fats that you eat. It also includes consuming fish high in omega-3 fatty acids and vegetable oils that can help lower blood cholesterol levels and the risk of cardiovascular disease. The Therapeutic Lifestyle Changes diet and the DASH Eating Plan can help you lower your bad low-density lipoprotein (LDL) cholesterol. These plans also encourage eating whole grains, fruits, and vegetables rather than refined carbohydrates such as sugar. Talk to your doctor about other nutritional changes that you can make.
  • Being physically active. There are many health benefits to being physically active and getting the recommended amount of physical activity each week. Studies have shown that physical activity can lower LDL cholesterol and triglycerides and increase good high-density lipoprotein (HDL) cholesterol. Before starting any exercise program, ask your doctor what level of physical activity is right for you.
  • Aiming for a healthy weight. If you have high blood cholesterol and are overweight or obese, you can improve your health by aiming for a healthy weight. Research has shown that adults with overweight and obesity can reduce LDL cholesterol and increase HDL cholesterol by losing only 3 percent to 5 percent of their weight. Achieving 5 percent to 10 percent weight loss in 6 months is recommended.
  • Managing stress. Research has shown that chronic stress can sometimes increase LDL cholesterol levels and decrease HDL cholesterol levels.
  • Quitting smoking
- Medicines

If you are unable to lower or control your high blood cholesterol levels with lifestyle changes alone, your doctor may prescribe a medicine.

  • Statins inhibit cholesterol synthesis in the liver by blocking the protein HMG-CoA reductase from making cholesterol. Liver cells try to compensate for the low cholesterol by synthesizing more LDL receptors on the cell surface to increase LDL uptake from blood. Statins are the most common medicine used to treat high blood cholesterol in people who are 10 years old or older. In certain cases, doctors may prescribe statins in people younger than 10 years old. Visit the Food and Drug Administration (FDA) Controlling Cholesterol with Statinsexternal link for more information about statins.
  • PCSK9 inhibitors lower LDL cholesterol by decreasing the destruction of LDL receptor in the liver, which helps remove and clear LDL cholesterol from the blood.
  • Bile acid sequestrants block the reabsorption of bile acids and increase conversion of cholesterol to bile acids. This has the effect of lowering plasma cholesterol levels.
  • Ezetimibe blocks dietary cholesterol from being absorbed in the intestine.
  • Fibrates promote removal of very low-density lipoprotein (VLDL) cholesterol, part of non-HDL.
  • Lomitapide blocks the liver from releasing VLDL cholesterol into the blood. It is used only in patients who have familial hypercholesterolemia.
  • Mipomersen decreases levels of non-HDL cholesterol in the blood. It is used only in patients who have familial hypercholesterolemia.
  • Niacin (nicotinic acid) decreases bad LDL cholesterol and triglycerides and raises HDL cholesterol.

If your doctor prescribes medicines as part of your treatment plan, be sure to continue your healthy lifestyle changes. The combination of the medicines and the heart-healthy lifestyle changes helps to lower and control your high blood cholesterol. Talk to your doctor about possible side effects to help decide which medicine is best for you.

- Lipoprotein apheresis

Some patients with familial hypercholesterolemia may benefit from lipoprotein apheresis to lower their blood cholesterol levels. Lipoprotein apheresis is a dialysis-like process in which LDL cholesterol is removed from the blood by a filtering machine, with the remainder of the blood being returned to the patient.

Living With

Follow up with your doctor periodically to see how well your treatment is working, whether you need to add or change medicines, and whether your health condition has changed.

  • Heart-healthy lifestyle changes. Initially, your doctor will recommend that you adopt lifelong lifestyle changes, including heart-healthy eating, being physically active, quitting smoking, managing stress, and managing your weight. Your doctor may refer you to a registered dietitian and an exercise physiologist.
  • Medicines. If heart-healthy lifestyle changes alone are not enough, your doctor may prescribe a statin or other medicine to help lower or control your high blood cholesterol levels.
  • Additional blood tests to screen for side effects of medicines or changes in health. Your doctor may order creatine kinase blood tests if you experience symptoms such as muscle fatigue, aching, tenderness, or stiffness while taking a statin. Liver enzyme tests can help determine whether a statin or other medicine is affecting your liver. Blood glucose tests can determine whether you have diabetes.

High blood cholesterol increases your risk of cardiovascular complications such as a heart attack or stroke. Your doctor may periodically evaluate your risk for these complications by using a calculator such as the Atherosclerotic Cardiovascular Disease Estimatorexternal link. This calculator estimates your risk of having a heart attack or stroke in the next 10 years. It considers your total and good high-density lipoprotein (HDL) cholesterol levels, age, and systolic blood pressure. It also factors in whether you have diabetes, smoke, or use medicines to control high blood pressure.

Your doctor will consider how unhealthy your blood cholesterol levels are and your 10-year risk calculation when deciding how best to treat your high blood cholesterol and to manage your risk of cardiovascular complications. Your doctor may recommend aspirin to prevent a first heart attack or stroke.

Keep in mind that this 10-year cardiovascular risk calculator may not accurately estimate risk in certain situations, such as when you are taking a statin; or in certain populations, such as Asians, Hispanics, or Native Americans.

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