High cholesterol (hypercholesterolaemia)

Overview

High cholesterol does not usually cause symptoms, so a blood test is the only way to find out whether someone has it. Having too much cholesterol in the blood can narrow the arteries, which raises the risk of heart attack and stroke. Heart UK says lifestyle, genes and overall health can all have an effect on cholesterol, and these can add up. Treatment starts with lifestyle changes such as healthier eating and more activity, and some people also need medicine.

Symptoms

What a clinician may find

• Familial hypercholesterolaemia can cause lumps around the knuckles, knees or the back of the ankle, a pale ring around the coloured part of the eye, or small yellow patches on the skin around the eyes.
• There are usually no symptoms of high cholesterol.

Complications

• Having too much cholesterol in the blood can narrow the arteries as fatty material builds up, which raises the risk of heart attack and stroke.
• Familial hypercholesterolaemia is the most common genetic cause of early cardiovascular disease, the Genomics Education Programme says.

Diagnosis

High cholesterol does not usually cause symptoms, so a blood test is the only way to find out whether someone has it. A lipid profile blood test measures HDL cholesterol, non-HDL cholesterol, the cholesterol ratio, triglycerides and total cholesterol. The British Heart Foundation says a GP can use the results to say which targets apply, because these depend on individual risk. Other causes of high cholesterol, such as diabetes or an underactive thyroid, are excluded first when familial hypercholesterolaemia is suspected. A scoring guide such as the Simon Broome criteria may be used, and genetic testing can confirm the diagnosis in some cases.

Treatment

Treatment starts with lifestyle changes such as healthier eating and more activity, and some people also need medicine. Statins are the most common medicine for high cholesterol, usually taken as a daily tablet and often for the long term. If statins do not suit a person or are not enough, the NHS lists other medicines such as ezetimibe, bempedoic acid and some injected medicines.

Prevention

The main NHS advice is to eat less saturated fat, be more active, stop smoking and cut back on alcohol.

Key facts

What is high cholesterol?

High cholesterol, also called hypercholesterolaemia, means there is too much cholesterol in the blood. High cholesterol does not usually cause symptoms, so a blood test is the only way to find out whether someone has it. Cholesterol travels in the blood in different forms. HDL cholesterol is often called the good type because it carries excess cholesterol back to the liver, while non-HDL cholesterol is the bad type and can build up in the arteries, the British Heart Foundation says. Having too much cholesterol in the blood can narrow the arteries as fatty material builds up, which raises the risk of heart attack and stroke. The NHS describes heart and blood vessel problems caused by high cholesterol as cardiovascular disease. Triglycerides are another type of fat in the blood, and they can also add to fatty build-up in the arteries. Heart UK says anyone can have a higher cholesterol level, even people who are slim, eat well and are physically active.

What causes high cholesterol?

Heart UK says lifestyle, genes and overall health can all have an effect on cholesterol, and these can add up. Lifestyle factors include drinking more alcohol than recommended, excess weight (especially around the middle), smoking, a diet high in saturated fat and low physical activity. The British Heart Foundation lists the main sources of saturated fat as fatty meats, full fat dairy products such as butter and cream, palm and coconut oil, and processed foods such as biscuits, cakes and pastries. The British Heart Foundation says that cholesterol in foods such as eggs and shellfish has only a minimal effect for most people, while saturated fat matters more.

High cholesterol can run in families. Heart UK says the risk is higher for people with a close relative, such as a parent or sibling, who has had high cholesterol or cardiovascular disease. The NHS says people are more likely to develop high cholesterol if they are over 50, male, past the menopause, or of South Asian or sub-Saharan African origin. Heart UK says familial hypercholesterolaemia is a common inherited condition caused by a change in one gene, which makes the liver less able to remove excess LDL cholesterol. Familial hypercholesterolaemia is the most common genetic cause of early cardiovascular disease, the Genomics Education Programme says.

How is high cholesterol diagnosed?

A GP may suggest a cholesterol test depending on factors such as age, weight and other conditions like high blood pressure or diabetes. The NHS Health Check, offered to some adults without certain existing conditions, includes a cholesterol test. The NHS says a cholesterol test can also be done at some pharmacies, sometimes for a fee. A lipid profile blood test measures HDL cholesterol, non-HDL cholesterol, the cholesterol ratio, triglycerides and total cholesterol. The British Heart Foundation says a GP can use the results to say which targets apply, because these depend on individual risk.

Other causes of high cholesterol, such as diabetes or an underactive thyroid, are excluded first when familial hypercholesterolaemia is suspected. A scoring guide such as the Simon Broome criteria may be used, and genetic testing can confirm the diagnosis in some cases. Familial hypercholesterolaemia can cause lumps around the knuckles, knees or the back of the ankle, a pale ring around the coloured part of the eye, or small yellow patches on the skin around the eyes. NICE advises two measurements of LDL cholesterol because results can vary for biological and analytical reasons. NICE recommends referral to a specialist lipid clinic to confirm the diagnosis, counsel the person and start cascade testing, which means testing relatives.

How is high cholesterol treated?

Treatment starts with lifestyle changes such as healthier eating and more activity, and some people also need medicine. The NHS says that for some people lifestyle changes alone are not enough. Statins are the most common medicine for high cholesterol, usually taken as a daily tablet and often for the long term. The NHS says most people can take statins, but they are not suitable for everyone, for example people with severe liver disease or who are pregnant. Atorvastatin is a statin used to lower cholesterol and to prevent heart disease, including heart attacks and strokes. The NHS says atorvastatin works by stopping the liver from making cholesterol. NICE guidance on lipid modification recommends atorvastatin as the statin to offer for preventing cardiovascular disease.

If statins do not suit a person or are not enough, the NHS lists other medicines such as ezetimibe, bempedoic acid and some injected medicines. The NHS says ezetimibe is prescribed if someone cannot take statins or a statin is not working for them, and it reduces the cholesterol absorbed from food. For familial hypercholesterolaemia, NHS England guidance describes lipid-lowering medicine, which will be life-long, as the first line of treatment.

Living with high cholesterol and getting help

The NHS advises eating less saturated fat, choosing unsaturated fats such as those in oily fish, olive oil, nuts and seeds, and being more active. The NHS also advises stopping smoking and cutting back on alcohol. Heart UK says regular aerobic exercise that raises the heart rate can improve LDL levels and lower triglycerides. Heart UK also says that losing weight can help raise HDL cholesterol, and that stopping smoking can too. Heart UK says losing excess weight and getting regular exercise can often lower triglyceride levels.

A GP appointment is the usual route for a cholesterol check, and the GP reads the result alongside other risk factors. Sudden chest pain or signs of a stroke need an emergency call to 999.

Frequently asked questions