What is High Cholesterol?
High cholesterol refers to elevated levels of lipids in the blood, primarily low-density lipoprotein cholesterol (LDL-C), which is the primary driver of atherosclerosis and coronary heart disease. 1
Understanding Cholesterol Components
Cholesterol exists in several forms, each with distinct clinical significance:
- LDL cholesterol ("bad cholesterol"): The primary atherogenic lipoprotein that deposits cholesterol in arterial walls, directly causing plaque formation and cardiovascular disease 1
- HDL cholesterol ("good cholesterol"): Protective lipoprotein that removes cholesterol from tissues; levels ≥60 mg/dL are considered a "negative" risk factor that actually reduces cardiovascular risk 1
- Triglycerides: Fat molecules in blood; levels ≥500 mg/dL require immediate attention to prevent pancreatitis 1
- Total cholesterol: Sum of all cholesterol types; levels >240 mg/dL are considered "high" 1, 2
Risk Stratification: Who Needs Treatment?
Treatment intensity depends on your absolute cardiovascular risk, not just cholesterol numbers alone. 1 The following risk factors determine how aggressively to treat:
Major Risk Factors That Modify Treatment Goals 1:
- Age: Men >45 years, women >55 years
- Smoking: Current cigarette use
- Hypertension: Blood pressure ≥140/90 mmHg or on medication
- Low HDL: <40 mg/dL
- Family history: First-degree male relative with CHD <55 years or female <65 years
- Diabetes: Automatically considered equivalent to having existing heart disease
Risk Categories and LDL Goals 1:
Highest Risk (CHD or equivalent):
- LDL goal: <100 mg/dL
- Includes: existing heart disease, diabetes, 10-year CHD risk >20%
- Start lifestyle changes at LDL ≥100 mg/dL
- Consider drugs at LDL ≥130 mg/dL (optional at 100-129 mg/dL)
Moderate-High Risk (≥2 risk factors, 10-20% 10-year risk):
- LDL goal: <130 mg/dL
- Start lifestyle changes at LDL ≥130 mg/dL
- Consider drugs at LDL ≥160 mg/dL
Moderate Risk (≥2 risk factors, <10% 10-year risk):
- LDL goal: <160 mg/dL
- Start lifestyle changes at LDL ≥160 mg/dL
- Consider drugs at LDL ≥190 mg/dL (optional at 160-189 mg/dL)
Management Strategy
Step 1: Therapeutic Lifestyle Changes (First-Line for All) 1
Diet modifications 1:
- Reduce saturated fat intake
- Increase fruits and vegetables
- Limit dietary cholesterol
Physical activity 1:
- Regular exercise program
- Helps raise HDL and lower triglycerides
Weight management 1:
- Achieve and maintain healthy body weight
- Particularly important for metabolic syndrome
Step 2: Drug Therapy When Indicated 1, 3
Statins are the primary medication class for LDL reduction, with proven mortality benefit in high-risk patients 1. Atorvastatin (and other statins) work by blocking cholesterol synthesis in the liver 3.
Key statin considerations 3:
- Take daily at any time, with or without food
- Monitor liver enzymes periodically
- Report unexplained muscle pain, tenderness, or weakness immediately (risk of rhabdomyolysis)
- May cause small increases in blood glucose (HbA1c)
- Contraindicated in pregnancy and breastfeeding
- Avoid excessive alcohol (>2 drinks daily)
Drug interactions requiring dose adjustment or alternative therapy 3:
- Immunosuppressants (cyclosporine)
- Certain antibiotics (erythromycin, clarithromycin)
- Antifungals (itraconazole, ketoconazole)
- HIV/hepatitis C medications
- Fibrates (gemfibrozil)
Special Considerations
When triglycerides are 200-500 mg/dL 1:
- Non-HDL cholesterol (total cholesterol minus HDL) becomes a secondary target
- Non-HDL goal is 30 mg/dL higher than LDL goal
- Useful when triglycerides make LDL calculation unreliable
When triglycerides are ≥500 mg/dL 1:
- Triglyceride reduction becomes the primary goal to prevent pancreatitis
- LDL calculation using standard formulas is invalid
Monitoring and Follow-Up
Initial monitoring 1:
- Recheck lipids after 3-6 months of lifestyle changes
- If drug therapy initiated, assess response and tolerability
- Annual lipid panels for most adults
- Every 2 years if consistently at low-risk levels with favorable profile
- Focus on overall cardiovascular risk, not isolated numbers
Common Pitfalls to Avoid
Do not treat cholesterol numbers in isolation 1: Always assess total cardiovascular risk using validated tools (Framingham risk calculator) that incorporate age, blood pressure, smoking, and diabetes status.
Do not ignore secondary causes 6: Before treating primary hyperlipidemia, rule out hypothyroidism, diabetes, kidney disease, liver disease, and medication effects (especially in new-onset cases).
Do not stop statins abruptly without medical guidance 3: Patients often discontinue therapy due to perceived side effects; discuss concerns with healthcare provider before stopping.
Do not assume high HDL requires treatment 4, 5: HDL ≥60 mg/dL is protective and should not be lowered; focus remains on LDL reduction and overall risk management.