High Cholesterol

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Harvard Medical School
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High Cholesterol

Heart and Circulatory
Risks and Prevention
High Cholesterol
High Cholesterol
The buildup of plaque that can bring you down.
InteliHealth Medical Content

Reviewed by the Faculty of Harvard Medical School

High Cholesterol


What Is Cholesterol?

Cholesterol may already be familiar to you as a risk factor for coronary-artery disease. But cholesterol is also vital to good health. Cholesterol is a type of a lipid, a soft, fat like substance that serves as a source of fuel and contributes to cell structure, the manufacturing of hormones and other biological functions. Cholesterol is manufactured by the liver. (In fact, your body manufactures all the cholesterol you need from other fats in your diet; you don't need to consume any cholesterol to maintain health.) You can also get cholesterol from consuming animal foods, such as meat, eggs and dairy products.

Too Much

Although cholesterol is vital to a variety of life-sustaining functions, too much cholesterol in your blood is a major risk factor for heart disease. Excessive cholesterol can cause buildup of atherosclerotic plaque. Accumulation of plaque in arteries can block blood flow and lead to a heart attack.

What Causes Excessive Cholesterol?

To understand how excessive cholesterol occurs, consider how cholesterol travels in your body. Cholesterol doesn't dissolve in water. Therefore, to circulate through your blood (which is mostly made up of water), cholesterol and triglycerides (another lipid in the blood) combine with proteins to form lipoproteins.

There are four types of lipoproteins, each differing in the ratio of cholesterol and triglycerides to protein. The main types are low-density lipoprotein (LDL) and high-density lipoprotein (HDL).

LDL cholesterol, the so-called "bad" cholesterol, is transported to sites throughout the body where it's used to repair cell membranes or make hormones. LDL cholesterol can accumulate in the walls of your arteries, just as hard water promotes a buildup of lime inside the plumbing of your house. Cholesterol deposits, however, are spotty, rather than evenly coated, throughout the arteries.

HDL, the so-called "good" cholesterol, is transported to the liver, where it's altered and removed from the body. In a sense, HDL is the clean-up crew that sops up excess cholesterol from the tissues and disposes of it before it can do any damage. In fact, there is no good cholesterol. It is the lipoprotein HDL that is "good," not the cholesterol it carries. But laboratories measure HDL cholesterol rather than HDL itself.

Using Cholesterol to Measure Heart Disease Risk

No single cholesterol or ratio of cholesterol numbers provides an absolute standard for measuring heart-disease risk. Your lipid profile includes the following measurements: total cholesterol, LDL cholesterol, HDL cholesterol and triglycerides.

Total cholesterol, LDL cholesterol, and HDL cholesterol reflect a dynamic process — cholesterol is deposited in the walls of blood vessels and then taken away. The total cholesterol level is the crudest look at this process; the LDL and HDL numbers give a more detailed look at the two-way traffic inside your blood vessels. Ideally, LDL cholesterol levels should be less than 100 milligrams per deciliter (mg/dL). An HDL cholesterol level under 40 mg/dL is low; a level of 60 mg/dL or above is excellent.

Understanding Triglycerides

Like cholesterol, triglycerides are lipids that circulate in your blood. Triglycerides are used by the body to transport and store fat. The relationship between high triglyceride levels and heart disease is complex; clearly, however, high triglyceride levels aren't good for health. High triglyceride levels accompanied by low HDL levels appear to be especially worrisome.

Cholesterol and Triglyceride Levels

Here is information that helps guide you and your doctor about what your cholesterol and triglyceride levels mean for your. THey are based on guidelines issued by the National Cholesterol Education Program Expert Panel.

LDL Cholesterol
Less than 100 Optimal
100 to 129 Desirable
130 to 159 Borderline high
160 to 189 High
190 or greater Very high
Total Cholesterol
Less than 200 Desirable
200 to 239 Borderline high
240 or greater High
HDL Cholesterol
Less than 40 Low
60 or greater High
Less than 150 Optimal


New Guidelines

Doctors previously used the numbers above to determine when to prescribe cholesterol-lowering drugs. Statins are recognized as the best class of cholesterol-lowering drugs to prevent heart attack, stroke and artery diseases caused by fatty build-up. That’s because statins do much more than just lower the LDL number.

The American Heart Association (AHA) and the American College of Cardiology (ACC) released new guidelines in November 2013. The guidelines focus on who should take a statin.

The guidelines take away a target-LDL goal approach. Instead, they recommend using risk to determine when people should take a statin to lower cholesterol. High risk of a heart attack, stroke or artery related disease is indicated for:

  1. People with a history of atherosclerosis (coronary artery disease, stroke or other artery disease)
  2. People ages 40 to 75 who have diabetes
  3. People with very high LDL cholesterol (at or above 190 mg/dL)
  4. People who have a 10-year risk of heart attack OR stroke that is more than 7.5% without a statin. The AHA and ACC have developed a risk calculator that is available online. The calculator takes into account your age, race, smoking history, cholesterol levels and whether or not you have diabetes or high blood pressure.

You work up to a certain "intensity" of statin therapy, based on the type of statin and the amount you take.

  • Moderate-intensity therapy lowers LDL by 30% to 50%.
  • High-intensity therapy lowers LDL by 50% or more.

The guidelines help your doctor to match the intensity of statin therapy to your risk. The higher your risk, the more intense the cholesterol-lowering will be.

Factors That Affect Cholesterol Levels

Factors that affect cholesterol levels include diet, exercise and genetics.


Significantly large amounts of saturated fat and trans fat in your diet can increase your cholesterol levels, more so than anything else you eat. Saturated fat is found in animal foods such as meat, fish, poultry and whole-milk dairy products, such as cream, milk, ice cream and cheese. Saturated fat is also found in butter, lard and coconut, palm kernel and palm oils. Your body easily turns saturated fat into cholesterol, which ends up in the walls of your arteries.

Trans fats are fats that start out as liquid vegetable oils, and then are transformed by a chemical process (hydrogenation) into solids at room temperature. This process turns healthy vegetable oils into unhealthy fats that raise LDL cholesterol and lower HDL cholesterol.

If you are trying to modify your diet to improve your lipid profile, focus on reducing the amount of saturated fat and trans fat in your diet rather than the absolute amount of cholesterol.


Regular aerobic exercise reduces your blood levels of triglycerides and increases your levels of beneficial HDL cholesterol.


Your genes can affect your cholesterol levels. Because of abnormal genes inherited from their parents, some people lack certain cell receptors that are needed for removing LDL from the blood. In this condition, called familial hypercholesterolemia, people can have extremely high levels of LDL cholesterol. This results from inheriting one bad gene (these people are called heterozygotes) or two bad genes (called homozygotes). Heterozygotes can develop premature coronary-artery disease, usually in their 40s to 60s, whereas homozygotes can die of heart attacks in their teens or 20s. There are also milder forms of hypercholesterolemia, which generally produce moderate elevations of cholesterol and proportionally increased risk of premature heart attacks.

Medications to Lower Cholesterol Levels

Reducing your cholesterol and other levels of blood fats should begin with lifestyle changes, such as following a low-fat diet and controlling weight, but a number of drugs can lower total cholesterol, LDL and triglyceride levels, while increasing beneficial HDL levels. If your cholesterol levels are high despite dietary changes, talk to your doctor about how to reduce them with these lipid-lowering medications:

Drug Category: Statins are almost always the drug of choice to lower total and LDL cholesterol levels.

How They Work: Statins block the production of cholesterol.
Some Common Agents: Lovastatin, pravastatin, simvastatin, fluvastatin, atorvastatin, rosuvastatin

Drug Category: Niacin
How They Work: Niacin reduces the liver's ability to produce very low-density lipoprotein, the precursor of LDL.
Some Common Agents: Nicotinic acid, niacin extended-release (Niaspan), niacin (Slo-Niacin)

Drug Category: Fibrates
How They Work: Fibrates activate an enzyme that speeds the breakdown of triglycerides in the blood.
Some Common Agents: Clofibrate (Atromid), gemfibrozil (Lopid), fenofibrate (Tricor)

Drug Category: Bile acid sequestrants
How They Work: These drugs bind with bile acids (which are made from cholesterol) in the intestines and remove them in the stool. More cholesterol is then used by the liver to make bile acids.
Some Common Agents: Cholestyramine, colestipol

Drug Category: Cholesterol absorption blockers
How They Work: They decrease total serum and LDL cholesterol levels by inhibiting absorption of cholesterol from the intestinal tract.
Some Common Agents: Ezetimibe (Zetia) is currently the only one approved from this category.


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Last updated January 28, 2015

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