What is the difference between Hypercholesterolemia (high cholesterol), Hyperlipidemia (elevated lipids), and Mixed Hyperlipidemia (combined hyperlipidemia)?

From the Guidelines

Hypercholesterolemia, hyperlipidemia, and mixed dyslipidemia should be treated with statins as the first-line therapy, as they have been shown to reduce cardiovascular morbidity and mortality by decreasing LDL cholesterol levels. Hypercholesterolemia, hyperlipidemia, and mixed dyslipidemia are distinct but related lipid disorders that differ in which blood lipids are elevated 1. Hypercholesterolemia specifically refers to elevated total cholesterol and LDL cholesterol levels, while normal triglyceride levels are maintained. Hyperlipidemia is a broader term that encompasses any elevation in blood lipids, including cholesterol, triglycerides, or both. Mixed dyslipidemia (or mixed hyperlipidemia) specifically describes the condition where both cholesterol and triglyceride levels are elevated simultaneously.

Key differences between these conditions include:

• Hypercholesterolemia: elevated total cholesterol and LDL cholesterol levels
• Hyperlipidemia: elevation in blood lipids, including cholesterol, triglycerides, or both
• Mixed dyslipidemia: elevation of both cholesterol and triglyceride levels According to the European guidelines on cardiovascular disease prevention in clinical practice 1, statins are the preferred treatment for hypercholesterolemia and combined hyperlipidemia, as they effectively reduce LDL cholesterol levels by 50% and halt progression or even contribute to regression of coronary atherosclerosis.

Treatment approaches may vary based on the specific disorder, but statins should be used as the drugs of first choice in patients with hypercholesterolaemia or combined hyperlipidaemia 1. Lifestyle modifications, such as a Mediterranean or DASH diet, regular exercise, weight management, smoking cessation, and limiting alcohol intake, are fundamental for all types of lipid disorders and can help reduce cardiovascular disease risk 1.

From the FDA Drug Label

Fenofibrate tablets are indicated as adjunctive therapy to diet to reduce elevated low-density lipoprotein cholesterol (LDL-C), total cholesterol (Total-C), Triglycerides and apolipoprotein B (Apo B), and to increase high-density lipoprotein cholesterol (HDL-C) in adult patients with primary hypercholesterolemia or mixed dyslipidemia. Fenofibrate tablets are also indicated as adjunctive therapy to diet for treatment of adult patients with severe hypertriglyceridemia.

The main difference between hypercholesterolemia, hyperlipidemia, and mixed dyslipidemia is:

• Hypercholesterolemia refers to elevated levels of LDL-C (bad cholesterol).
• Hyperlipidemia is a broader term that refers to elevated levels of lipids (fats) in the blood, including triglycerides and cholesterol.
• Mixed dyslipidemia refers to a combination of elevated triglycerides and LDL-C, with low levels of HDL-C (good cholesterol).

Fenofibrate is used to treat all three conditions, with the goal of reducing LDL-C, total cholesterol, and triglycerides, while increasing HDL-C 2, 2.

From the Research

Hypercholesterolemia vs Hyperlipidemia vs Mixed

• Hypercholesterolemia refers to high levels of cholesterol in the blood, which can lead to atherosclerotic disease and increase the risk of acute coronary events 3.
• Hyperlipidemia is a broader term that encompasses high levels of lipids, including cholesterol and triglycerides, in the blood 4.
• Mixed hyperlipidemia, also known as combined hyperlipidemia, is a condition characterized by elevated levels of both cholesterol and triglycerides in the blood 5, 4.

Treatment Options

• Statin therapy is a mainstay in the treatment of hypercholesterolemia, but it also has side effects that may lead to patient noncompliance 3.
• Combination therapy, such as adding niacin or fibrates to statins, may be considered for patients with mixed hyperlipidemia 5.
• Lifestyle changes, including physical activity, are recommended as first-line treatment for patients with mildly or moderately elevated blood pressure and blood cholesterol 6.
• Other treatment options, such as bile acid sequestrants, ezetimibe, and proprotein convertase subtilisin/kexin type 9 (PCSK9) enzyme inhibitors, may be considered for patients who cannot tolerate statins or require additional therapy 7.

Management Guidelines

• Current guidelines recommend lifestyle approaches, including physical activity, as first-line treatment for elevated blood pressure and cholesterol 6.
• The American Heart Association and the American College of Cardiology recommend statin therapy for adults aged 40-75 years old with at least one risk factor and a calculated 10-year cardiovascular disease risk of 10% 7.
• The management of mixed hyperlipidemia involves determining the underlying cause and optimizing therapy to improve prognosis from atherosclerotic disease 4.