High Cholesterol

What cholesterol is

Cholesterol is a waxy fat that the body uses to build cells and make hormones and vitamin D. The liver makes most of it; the rest comes from food. Cholesterol travels in the blood on particles called lipoproteins:

• LDL (low-density lipoprotein): carries cholesterol to tissues. Excess LDL enters artery walls and forms plaque. Lower is better
• HDL (high-density lipoprotein): carries cholesterol back to the liver. Higher levels are associated with lower risk, but raising HDL with drugs has not reduced heart disease
• Triglycerides: another blood fat, raised by excess calories, sugar, alcohol and diabetes
• Lipoprotein(a): a genetically determined particle that adds independent risk

Cholesterol levels explained

Your target depends on your overall risk. People who have had a heart attack or stroke, or have diabetes or very high risk, are usually treated to much lower LDL levels.

Causes and risk factors

• diet high in saturated fat (fatty meats, butter, full-fat dairy, coconut and palm oil) and trans fat
• excess weight, especially around the waist
• physical inactivity
• smoking, which also lowers HDL
• genetics: familial hypercholesterolemia affects about 1 in 250 people and causes very high LDL from birth
• age, and menopause in women
• medical conditions: type 2 diabetes, hypothyroidism, kidney disease (nephrotic syndrome), liver disease, metabolic syndrome
• medicines: some diuretics, steroids, retinoids, some HIV drugs and immunosuppressants

Symptoms and complications

High cholesterol has no symptoms on its own. The first sign may be a heart attack or stroke. Some people, especially with familial hypercholesterolemia, develop:

• xanthelasma: yellow plaques on the eyelids
• tendon xanthomas: firm lumps on the Achilles tendons or knuckles
• corneal arcus: a gray-white ring around the iris before age 45

Over time, LDL drives atherosclerosis, which leads to:

• coronary artery disease, angina and heart attack
• stroke and transient ischemic attack
• peripheral artery disease: leg pain on walking, poor wound healing

Testing

A lipid panel blood test measures total cholesterol, LDL, HDL and triglycerides. Fasting is often not required. The AHA recommends checking every 4 to 6 years from age 20 in healthy adults, and children once between ages 9 and 11 (earlier with a family history). Doctors combine results with age, sex, blood pressure, diabetes and smoking status to estimate your 10-year cardiovascular risk. A one-time lipoprotein(a) test and a coronary artery calcium scan can refine risk in some people.

How to lower cholesterol

Lifestyle

• Eat less saturated fat: choose lean proteins, fish, beans and plant oils (olive, canola) instead of butter and fatty meat.
• Avoid trans fats.
• Eat more soluble fiber: oats, barley, beans, lentils, apples, citrus. 5 to 10 g a day can lower LDL modestly.
• Add plant sterols and nuts.
• Exercise: at least 150 minutes of moderate activity a week.
• Lose excess weight: even 5% to 10% helps.
• Stop smoking and limit alcohol.

Lifestyle changes can lower LDL by roughly 10% to 20%; results vary.

Medicines

• Statins (such as atorvastatin, rosuvastatin): first-line. They lower LDL by 30% to 50% or more and reduce heart attacks and strokes. Most people tolerate them well. Muscle aches occur in some, but true statin intolerance is less common than believed; switching dose or type often helps
• Ezetimibe: reduces cholesterol absorption from the gut; added to statins
• PCSK9 inhibitors (evolocumab, alirocumab) and inclisiran: injections that lower LDL by about 50% or more, used for very high risk or familial hypercholesterolemia
• Bempedoic acid: an option for people who cannot take statins
• For high triglycerides: lifestyle changes, treating diabetes, and in some cases icosapent ethyl or fibrates

The AHA/ACC recommend statins for people with existing cardiovascular disease, LDL of 190 mg/dL or higher, diabetes aged 40 to 75, and others whose estimated 10-year risk is elevated after a shared discussion.

Frequently asked questions

What is a normal cholesterol level?

For most adults, desirable levels are total cholesterol under 200 mg/dL, LDL under 100 mg/dL, HDL of 60 mg/dL or higher and triglycerides under 150 mg/dL. Your personal LDL target depends on your overall heart risk.

Does high cholesterol cause symptoms?

Usually not. Most people have no symptoms until a heart attack, stroke or circulation problem occurs. Some people with very high inherited cholesterol develop yellow deposits on the eyelids or tendons. A blood test is the only way to know your levels.

What causes high cholesterol?

Common causes include a diet high in saturated and trans fats, excess weight, inactivity, smoking, aging and genetics. Conditions such as diabetes, hypothyroidism and kidney disease, and some medicines, can also raise cholesterol.

How can I lower my cholesterol naturally?

Cut saturated and trans fats, eat more soluble fiber, nuts and plant oils, exercise regularly, lose excess weight, stop smoking and limit alcohol. If your risk is high or LDL stays elevated, medicines such as statins may also be needed.

Are statins safe?

For most people, yes. Statins are among the most studied medicines and reduce heart attacks and strokes. Side effects such as muscle aches can occur but are often manageable by changing the dose or type. Serious side effects are rare.