1. Hypercholesterolemia: What Is It?
Hypercholesterolemia is a lipid metabolism disorder in which elevated cholesterol levels are present in the blood. Literally, hypercholesterolemia means “too much cholesterol in the blood”, where “hyper” stands for “too much” and “-emia” is derived from the Greek word haĩma meaning “blood.”
Cholesterol is an important substance for our body. It is needed, for example, for the construction of cell membranes or for the production of certain hormones, vitamins, andbile acids. In principle, the body and every individual body cell are capable of producing cholesterol. However, most cholesterol is produced in the liver, and about 20–30% is obtained through food. If additional cholesterol is consumed through food, cholesterol production in the liver is normally reduced in response. However, this regulatory mechanism functions only to a limited extent and not equally well in all individuals, so cholesterol levels in the blood may remain elevated in the long term.
However, cholesterol is not all the same, as there are different types. Cholesterol is a fat-like substance that is not soluble in water or in blood. In order for cholesterol to be transported in the blood, it must bind to a water-soluble transport substance. This results in so-called lipoproteins. Depending on which lipoprotein transports the cholesterol, it is classified into different types. The so-called low-density lipoprotein (LDL cholesterol), which makes up the majority of the “cholesterol transporters”, transports cholesterol from the liver to the cells in the rest of the body. The high-density lipoprotein (HDL cholesterol) transports excess cholesterol from the remaining body cells to the liver, where it is broken down. In addition to the two main forms of lipoproteins, LDL cholesterol and HDL cholesterol, there are other forms such as VLDL cholesterol (very low-density lipoprotein) and chylomicrons.
2. Causes and Risk Factors
Hypercholesterolemia can have various causes, and multiple contributing factors often occur together. Depending on the cause, a distinction can be made between an acquired form or a congenital or genetically determined form of hypercholesterolemia.
An acquired hypercholesterolemia is in most cases a result of an unhealthy lifestyle, but it can also be caused by other diseases or by the use of certain medications. A high-fat diet, lack of physical activity, and overweight are common factors of an unhealthy lifestyle and can increase cholesterol levels. However, other conditions such as diabetes, hypothyroidism, rheumatism, and kidney or liver diseases can also be causes of hypercholesterolemia.
A familial hypercholesterolemia (FH) is a hereditary form of lipid metabolism disorder. The cause is a genetic alteration that leads to a disruption of LDL cholesterol metabolism, resulting in insufficient removal of LDL cholesterol from the blood. As a result, very high cholesterol levels occur in the blood already in childhood, significantly increasing the risk of cardiovascular disease. Familial hypercholesterolemia is not curable. However, early treatment can significantly reduce the risk of cardiovascular disease. In addition to a healthy lifestyle, medications are usually necessary to sufficiently reduce cholesterol levels.
3. Symptoms
Hypercholesterolemia alone usually does not cause any symptoms. It is therefore often detected late, during routine and preventive examinations or when complications such as a heart attack, a stroke, or coronary heart disease (CHD) occur. Detailed information on CHD is available on the information page on CHD.
In some cases, very high, often hereditary cholesterol levels can lead to visible nodular deposits under the skin, especially on the Achilles tendon, to swellings on the tendons of the hand, or to a whitish ring in the cornea of the eye. However, these symptoms are not definitive signs of hypercholesterolemia, but may also indicate other conditions. Nevertheless, they should be evaluated by a physician.
4. Complications
An elevated cholesterol level is usually not a noticeable condition, but it is an important risk factor for the development of cardiovascular disease. They contribute in the long term to so-called vascular calcification (atherosclerosis). Especially if the vessel walls are already damaged from the inside, for example due to smoking or diabetes, excess cholesterol from the blood can deposit on the vessel walls and so-called plaques may form. As a result, the blood vessels become narrowed. In addition, there is a risk that a plaque may detach and block a blood vessel. As a result, cardiovascular diseases such as a heart attack or stroke can occur.
In addition to hypercholesterolemia, there are many other risk factors for cardiovascular disease. The more risk factors a person has, the higher the risk of developing cardiovascular disease. Therefore, the individual risk should ideally be assessed together with the treating physician. Based on this, a strategy and therapy should then be developed to reduce the risk of complications as much as possible.
Risk factors for cardiovascular disease include, among others:
- High blood pressure
- Hypercholesterolemia
- Diabetes mellitus
- Smoking
- Obesity
- Unhealthy diet
- Sedentary lifestyle
- Increasing age
- Male sex
- Family history
5. Examinations
Cholesterol levels are determined by a blood sample that is analyzed in a laboratory. Among other things, total cholesterol and the different types of cholesterol (e.g. LDL cholesterol and HDL cholesterol) are measured. In general, cholesterol levels can be reported in two different units. On the one hand as milligrams per deciliter (mg/dL) and on the other hand as millimoles per liter (mmol/L). When assessing cholesterol levels, it may sometimes be useful to also examine other blood lipids in order to better evaluate lipid metabolism.
To detect changes at an early stage and to assess the success of lifestyle measures or therapy, it is advisable to monitor cholesterol levels regularly, document them, and compare them over time.
In the mediteo app, you have the option to document measurements such as total, HDL, or LDL cholesterol in the integrated diary and display them in a table or a clear graph, allowing changes over time to be easily tracked.
6. Normal Levels
Defining normal cholesterol levels is not entirely straightforward. In simple terms: The higher the cholesterol level, the higher the risk of cardiovascular disease. To reduce this risk, cholesterol levels should be lowered. Therefore, it may be more useful to speak of target values rather than normal values. Personal target values should be discussed with a physician and depend on the individual risk of cardiovascular disease. In principle, it can be said: The higher the individual risk, the lower the cholesterol level should be.
7. Treatment
The treatment of hypercholesterolemia aims to normalize elevated cholesterol levels. However, the focus is not on the laboratory value itself, but rather on the reduction of the risk of cardiovascular disease and its possible complications.
Not everyone with elevated cholesterol levels automatically requires medication. The decision regarding therapy depends on the individual risk of complications and the level of cholesterol.
The foundation of any therapy is a change in lifestyle habits. This includes quitting smoking, weight reduction in cases of overweight, physical activity, and a healthy diet. Care should be taken to reduce saturated fatty acids as much as possible and to prefer unsaturated fatty acids instead. Saturated fatty acids are considered “less healthy” fats and are found mainly in animal products such as meat and sausage. Unsaturated fatty acids are considered “healthier” fats and are found, for example, in fish, nuts, or avocados. In addition, care should be taken to include fiber-rich foods such as whole grains, legumes, vegetables, and fruit. The so-called Mediterranean diet, with olive oil, fish, and plenty of fresh fruit, vegetables, and salads, and as little meat and animal fats as possible, can, for example, help lower cholesterol levels.
These measures not only have a positive effect on cholesterol levels, but also reduce the risk of cardiovascular disease.
Whether an additional drug therapy is necessary depends on the cholesterol level, the individual risk of complications, and the success of lifestyle changes. The most commonly used active substances include statins, such as rosuvastatin or atorvastatin. They lower LDL cholesterol by inhibiting the body’s own cholesterol production in the liver. When taking statins, side effects such as headaches or gastrointestinal complaints, such as a feeling of fullness, abdominal pain, or flatulence, may sometimes occur. In rare cases, muscle pain and even muscle disorders may occur. In addition to statins, there are also other medications that are used to treat hypercholesterolemia. These can be used if the target values are not achieved with statin therapy or if statins are not tolerated. Other medications used to treat elevated cholesterol levels include cholesterol absorption inhibitors (ezetimibe), PCSK9 inhibitors, and bempedoic acid.
Which medication or combination of medications is best should be discussed individually with a physician.