High cholesterol
Cholesterol is neither a disease nor a poison in itself: no cell membrane gets built without it, and neither do the hormones or the bile.
On this page
Medicines commonly prescribed for High cholesterol
For informational purposes only. Always consult a doctor before using any medicine.
Dosage form: TABLET, 20 mgActive substance: atorvastatinManufacturer: Sandoz Farmaceutica S.A.Prescription requiredDosage form: TABLET, 10 mgActive substance: simvastatinManufacturer: Laboratorios Cinfa S.A.Prescription requiredDosage form: TABLET, 40 mgActive substance: atorvastatinManufacturer: Viatris Healthcare LimitedPrescription required
Cholesterol is neither a disease nor a poison in itself: no cell membrane gets built without it, and neither do the hormones or the bile. The trouble starts when there is too much of what carries it around the blood, and that surplus spends years leaving fat in the walls of the arteries. None of it can be felt — not as pain, not as tiredness, not in the colour of the face. People learn their numbers either from a blood test or from a heart attack. The difference between those two ways of finding out is the whole point of talking about cholesterol.
What actually settles in the arteries
Cholesterol does not dissolve in blood and travels packed into protein containers called lipoproteins. There are several kinds and they behave differently.
- LDL cholesterol delivers cholesterol to the tissues. It is the fraction that lodges in a damaged artery wall, and its quantity decides whether a plaque grows. This is the "bad" one, and it is the first thing brought down.
- HDL cholesterol collects the surplus and returns it to the liver. A high level goes with lower risk, but deliberately raising it with drugs makes no sense: attempts in that direction produced no benefit.
- Non-HDL cholesterol is all the cholesterol apart from the "good" kind — in other words, the sum of everything that goes into building plaques. Its practical advantage is that it needs no fasting.
- Triglycerides are a different blood fat. They respond above all to alcohol, sugar and spare weight, and at very high levels they threaten inflammation of the pancreas.
A plaque grows slowly, over decades, and for a long time does not obstruct the flow. The danger lies not in gradual narrowing but in the sudden kind: the cap of the plaque tears, a clot forms over the tear, and the artery closes within minutes. In the heart that is a heart attack, in the brain a stroke, in the leg an acute blockage. Which is why crushing chest pain lasting more than a few minutes, a drooping face, an arm that will not work or slurred speech mean calling an ambulance at once (112 across Europe) rather than driving yourself to hospital.
Why it cannot be felt, and who should be checked
High cholesterol produces no symptoms. Tiredness, blood pressure and spare weight say nothing about it: it is a laboratory value and it shows up only in a blood test. The single exception is the inherited form, in which the excess can become visible in the skin and the tendons; more on that below.
Every adult is worth testing at least once. Earlier and more often if:
- a parent, brother or sister had an early heart attack, stroke or artery surgery;
- high cholesterol has already been found in the family;
- there is raised blood pressure, diabetes, kidney disease or obesity;
- you smoke;
- the menopause has passed, after which the levels rise noticeably;
- you take medicines that shift the lipids, such as steroids or retinoids.
Before treating high cholesterol as a problem in its own right, the doctor rules out the conditions that push it up: an underactive thyroid, kidney and liver disease, poorly controlled diabetes, regular drinking. If one of those is behind it, the numbers come back down once the cause is treated.
How the test works and what the report says
Blood is taken from a vein; there is also a finger-prick version in which a drop goes onto a strip and the result appears within minutes. That is convenient for screening, but borderline values are confirmed in a laboratory.
Fasting beforehand is unnecessary for most people: food barely affects total, LDL and non-HDL cholesterol. You are asked to come on an empty stomach only when triglycerides are of specific interest or when a previous triglyceride result was high.
The report normally lists total cholesterol, LDL, HDL, non-HDL and triglycerides. Separately, it is worth measuring lipoprotein(a) once in a lifetime: its level is set genetically, does not shift with food or exercise, and when high it raises risk in its own right. Knowing it is useful because it changes how strictly everything else is handled.
Which numbers count as yours
There is no single normal figure for everybody: the target depends on how much total risk has accumulated. For a healthy adult with no risk factors the rough reference points are:
- total cholesterol below 5 mmol/L;
- non-HDL cholesterol below 4 mmol/L;
- LDL cholesterol below 3 mmol/L;
- HDL cholesterol above 1.0 mmol/L in men and above 1.2 mmol/L in women.
For somebody who has already had a heart attack or a stroke, or who lives with diabetes or kidney disease, those reference points do not apply: the target LDL is considerably lower and the doctor sets it. This is why "my cholesterol is nearly normal" means nothing without the rest of the picture.
To decide whether treatment is needed, the doctor works out not a single value but the probability of a cardiovascular event over the coming years. Age, sex, smoking, blood pressure, the lipid figures and associated illnesses all feed into it; in Europe, scales such as SCORE2 are used for the purpose. That overall assessment, and not the cholesterol number alone, determines whether changes to the diet will do or whether it is time to add a medicine.
The inherited form that must not be missed
Roughly one person in two to three hundred is born with a genetic fault that stops the liver clearing LDL cholesterol properly from the blood. This is familial hypercholesterolaemia. The level stays high from childhood, the arteries age decades ahead of schedule, and without treatment the heart attack arrives in a person's thirties, forties or fifties.
Suspicion is warranted when:
- total cholesterol is very high, of the order of 8 mmol/L or above, with LDL sitting around 5 mmol/L or higher;
- there have been early heart attacks and sudden deaths in young relatives;
- firm thickenings can be felt on the Achilles tendons or the tendons of the hands;
- there are flat yellowish deposits on the eyelids;
- a pale arc is visible at the edge of the cornea in somebody under forty-five.
The important consequence: once the diagnosis is confirmed in one family member, every blood relative should be tested, children included. That family sweep finds carriers before they have their first event, and it is one of the rare occasions when a single blood test genuinely saves several lives.
What food and daily habits change
The LDL level is driven less by the cholesterol on the plate than by saturated fat, from which the liver makes cholesterol in the first place.
Worth eating less of: butter, lard and ghee, fatty meat and sausages, hard cheese and cream, cakes and biscuits, and anything made with palm or coconut oil. In a category of their own are industrial trans fats, which are the worst of the lot.
Worth eating more of: olive and rapeseed oil, nuts and seeds, oily fish, vegetables, fruit and pulses, oats and wholegrains. The soluble fibre in oats and beans reduces the absorption of cholesterol, and it is one of the few dietary measures with a demonstrated effect.
What else works: about two and a half hours of moderate activity a week, which does little to LDL but lowers triglycerides and lifts HDL; losing weight; cutting back on alcohol, particularly with high triglycerides; and stopping smoking, which improves both the figures and the state of the artery wall.
Expectations are best kept honest. In most people, diet and exercise bring LDL down by roughly a tenth. For borderline figures that is enough; with high risk or the inherited form it is not, and stalling over medication in that situation costs years.
Statins and what else there is
Statins reduce the production of cholesterol in the liver and remain the mainstay: their effect on heart attacks and strokes is better studied than that of any other drug in the field. One tablet a day, usually taken continuously, because the level returns within weeks of stopping.
The questions that come up most:
- muscle aches. The complaint is common, but in trials where some participants received a dummy tablet and nobody knew which they were taking, the difference between the groups turned out to be tiny. So when there is discomfort the drug is switched, the dose lowered or a different schedule tried, rather than the treatment abandoned for good;
- the liver. Blood tests keep watch and serious disturbance is rare;
- pregnancy. Statins are not used in pregnancy, so plans are discussed in advance;
- grapefruit juice raises the blood level of certain statins and is not combined with them.
If a statin is not enough or does not suit, other agents are added or substituted: ezetimibe, which blocks the absorption of cholesterol in the gut, bempedoic acid, bile acid sequestrants and, for high triglycerides, fibrates. There are also injectable drugs that suppress the PCSK9 protein: they are given every two weeks or monthly, and one member of that group twice a year. These are kept for the inherited form and for very high risk.
The point of treatment is not a tidy line on a report but a plaque that does not rupture. That is why the drug is not dropped once the numbers look normal: the normality is what taking it achieves.
Online consultation
Cholesterol is a subject settled almost entirely on paper, so a remote appointment is fully adequate here. The doctor will read your lipid profile alongside your blood pressure, weight, age and family history, work out the risk and say plainly whether the answer is to watch, to change the diet or to start a medicine. Online is also a convenient place to establish whether and when the test should be repeated, to go through side effects and decide about switching drugs, and to consider whether relatives should be tested when the figures are suspiciously high. If the signs of a heart attack or stroke described above appear, what is needed is not a consultation but an ambulance.
This material is for information only and does not replace medical advice.
Consult with a doctor about High cholesterol
Discuss your symptoms and possible next steps with a doctor online.
Online doctors for High cholesterol
Discuss your symptoms and possible next steps for High cholesterol with a doctor online.
