High cholesterol is also known as hypercholesterolemia.
It is dyslipidemia, an elevation of blood lipid levels above the average threshold. Most of us know that high blood cholesterol levels are not a good thing.
Moreover, it is becoming one of the most common diseases globally as we lead a diet high in saturated fat and trans fat.
Treating high cholesterol levels requires changing your lifestyle. It is considered a modern disease because our current habits are triggering this health problem. But exercising more often, eating healthier, and keeping up with your lipid-lowering drugs requires changes in your daily life and motivation to make these changes.
Why would you change everything around you? High cholesterol levels won’t give you many signs and symptoms until it’s too late. So, many patients neglect their condition and do nothing. What they do not know is that hyperlipidemia has many long-term consequences.
In this article, we’re briefly covering the most important acute and chronic ailments associated with high cholesterol levels. Understanding them is vital to see the importance of prevention, even if you do not experience any immediate consequences.
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1) Coronary artery (heart) disease
Coronary artery disease, also known as coronary heart disease, is a health problem in the coronary arteries. These are tiny arteries located in the heart. They supply oxygen to the heart muscle. As such, they are crucial for maintaining our heart beating. If they fail to send enough oxygen to an area of the heart, patients initially experience angina. After that, patients could start to experience a heart attack.
In coronary artery disease, the primary abnormality is cholesterol plaque. It forms in the artery walls and becomes very hard. As they continue growing, the artery plaques obstruct the blood flow to the heart. This reduces the patient’s cardiovascular resistance and causes chest pain and other symptoms. Ultimately, coronary artery disease causes a heart attack.
Studies show that high cholesterol levels constitute one of the significant risk factors for coronary artery disease. The relationship between cholesterol levels and cardiovascular disease was clear back in 1953, and it is still evident. More recently, studies about types of cholesterol were made available. That’s how we identified LDL (low-density lipoprotein) cholesterol as “bad” cholesterol. It is the type of cholesterol that we want to control through cholesterol therapy.
A reduction of LDL cholesterol levels of 10% reduces the cardiovascular risk by 50% in 40-year-old people. On the other hand, HDL (high-density lipoprotein) cholesterol has been identified as “good” cholesterol, and 1 mg increases in this type of cholesterol can reduce the cardiovascular risk by 2-3%. An excellent way to raise your good cholesterol is physical activity, while dietary changes reduce bad cholesterol levels (1).
A stroke is a reduction of the blood flow to the brain, which causes a brain lesion. There are different types of stroke, depending on the cause and its effects on the body. For educational purposes, let’s break it down to a hemorrhagic and ischemic stroke. The extravasation of blood causes hemorrhagic stroke into the brain. Ischemic stroke is caused by insufficient blood flow to the brain cells.
Similar to coronaries, the arteries of the brain are very small. They are also essential to keep the brain working. A slight reduction of blood flow and insufficient oxygen causes a lesion in the brain. It is very similar to what happens in the heart, but this time the patient does not experience chest pain. Instead, they report intense headaches and both sensory and motor changes in one side of the body.
The relationship between ischemic stroke and high cholesterol levels is similar to that of coronary artery disease. It is an atherosclerotic plaque that forms in brain arteries and obstructs blood flow. As the lumen of the arteries becomes smaller, there’s increasing blood pressure upon the atherosclerotic plaque. At some point, the plaque breaks apart, and a blood clot forms. This obstructs the affected artery and cuts the blood flow almost entirely, causing a stroke.
Similar to coronary artery disease, high LDL cholesterol leads to higher stroke risk. On the contrary, higher HDL levels reduce the risk. As we reduce LDL cholesterol levels using statins and lifestyle changes, stroke risk is also reduced. According to studies, taking cholesterol medications can improve your risk by near 20% (2).
3) Heart attack
A heart attack is not exactly the same as coronary artery disease, but it is closely linked. We mentioned that coronary artery disease is a problem in the arteries of the heart. They grow atherosclerotic plaques, and these plaques are created by using LDL cholesterol.
Bad cholesterol is oxidized and then ingested by macrophages creating foam cells. A complex blend of foam cells, collagen, elastin, and muscle cells develop and keeps growing.
Coronary artery disease triggers a heart attack when this plaque goes through an additional process. It can be either erosion or rupture of the plaque. Plaque erosion occurs due to an increase in blood pressure. More commonly, the plaque ruptures at some point. Our circulating platelets perceive this rupture as a blood vessel rupture and start to create a blood clot. The blood clot obstructs the blood vessel or travels to a nearby artery, causing a complete blockage.
All of this happens in the context of hyperlipidemia. If we don’t have high cholesterol levels, atherosclerosis is less likely. Without atherosclerosis, there won’t be any plaque or rupture. No thrombi or blood clot will obstruct the arteries, and myocardial infarction won’t happen (3).
Lowering your cholesterol levels will have a positive effect on preventing myocardial infarction. Even patients with previous myocardial infarction lower their risk of reinfarction by maintaining low cholesterol levels. According to studies, a cholesterol reduction of 10% in patients with a prior heart attack will reduce the risk of reinfarction by up to 19% (4).
4) Peripheral arterial disease
We often hear about circulation problems, especially in patients with type 2 diabetes. However, peripheral artery disease is an underdiagnosed health problem. In most cases, this ailment is associated with atherosclerosis. This time, the atherosclerotic plaques are not found in the brain or heart arteries. They can be found in many other arteries, including the abdominal aorta or the iliac arteries. The disease often takes the lower extremities because they need to work around gravity to favor blood flow.
According to the Framingham study, one of the most important cardiovascular risk factor studies, hyperlipidemia doubles peripheral artery disease risk. Around 60% of patients with peripheral arterial disease also have high cholesterol levels. Moreover, having high cholesterol levels increases your baseline risk of peripheral artery disease by 10% for every 10 mg increase of cholesterol levels.
Treatment of peripheral artery diseases requires to lower cholesterol levels. According to studies, having high total cholesterol and low HDL levels increases your risk, especially when C-reactive protein levels also increase. C-reactive protein is an inflammation marker. Thus, by keeping inflammation under control, increasing your HDL, and lowering your LDL, the risk will be reduced.
In patients with the disease, their annual decline is not as bad if they keep their blood fat levels under control. Thus, LDL levels should be below 100 mg/dL in the average patient and under 70 mg/dL in high-risk patients (5).
5) Blurred Vision
Vision is one of the most important sensory impulses to perceive what is happening around us. It is also one of the most fragile for many reasons.
One of them is that the eyes are exposed to the world around us and susceptible to infection, trauma, and debris. But it also has very small blood vessels and delicate structures. Any change in blood circulation is automatically reflected in the arteries of the eye-no wonder why people with diabetes suffer from visual problems as one of the manifestations of their disease. High cholesterol levels play a significant role.
Diabetic retinopathy can be proliferative when new blood vessels are formed or nonproliferative when patients mainly have hemorrhages and vascular abnormalities. A wide range of abnormalities can be found in each case, including edema and something called hard exudates. They are lipid leakages from the capillaries and are more common in patients with high cholesterol levels. These hard exudates contribute to the progression of diabetic retinopathy and blurred vision.
The mechanism is still unclear, but researchers propose that it is due to endothelial dysfunction. Serum lipids can cause injury to the endothelium in the eye blood vessels. If this is the case, high cholesterol can be harmful, and not only for diabetic patients (6).
6) Vascular Dementia
There are different types of dementia, and one of the most popular is Alzheimer’s disease. Vascular dementia is another type, and it is associated with blood vessel changes in the brain. These blood vessels fail to clear out toxins and do not carry enough oxygen and nutrients.
Vascular dementia can be found in different degrees, and not only in seniors. For example, a patient with a stroke who started losing his cognitive functions after recovering from the episode has a type of vascular dementia. Thus, the relationship between high cholesterol levels and dementia is partly due to an increase in stroke risk.
As noted throughout the article, there is also a link between cholesterol levels and vascular problems. High cholesterol levels contribute to an impairment in blood circulation. It causes atherosclerosis, which can affect virtually any artery of the body. Some researchers also propose that high cholesterol causes endothelial dysfunction. This can have side effects in the long-term.
According to studies, your blood cholesterol levels in midlife can affect your predisposition to suffer vascular dementia and Alzheimer’s disease as an older adult. Data from near 10,000 patients in California showed that people with cholesterol levels over 200 mg/dL are more likely to suffer from Alzheimer’s disease, vascular dementia, and other types of cognitive decline as they reach their golden years. Thus, the recommendation would be to control your cholesterol levels from an early age even if you do not have symptoms yet (7).
7) Erectile Dysfunction
Erectile problems are more common than we think, and 26 cases are diagnosed per 1000 men every year. The incidence increases as we age, especially in patients with diabetes, hypertension, and other chronic diseases.
There are different causes of erectile problems, but we can divide them roughly into two types: organic and psychogenic. Psychogenic causes are mainly related to emotions, stress, depression, and anxiety. Organic causes include cardiovascular and circulatory problems. Atherosclerosis is one of the organic causes of erectile dysfunction, especially in men over 40 years.
In patients with vascular erectile dysfunction, we often find an increase in LDL levels and a decrease in HDL levels. As noted above, high LDL levels play a significant role in atherosclerosis. This is the type of lipoprotein that becomes oxidized and turns into foam cells. Then, it triggers the development of atherosclerosis. In turn, atherosclerosis causes a reduction in the blood flow of the affected arteries. If the penile arteries are affected, the blood flowing to fill the penis won’t be enough for a full erection.
Erectile dysfunction should be treated according to its causes, and we can sometimes treat these vascular problems by reducing our circulating levels of cholesterol.
Studies show that erectile dysfunction caused by high cholesterol levels can be reversed. Lipid-lowering therapies should be used as an adjuvant treatment.
Keep in mind that this association is more commonly found in adults over 40 years. Younger adults and adolescents usually have a psychogenic and fully reversible cause of erectile dysfunction (8).
The diagnosis of high cholesterol levels falls into the guidelines of dyslipidemia. All blood lipid alterations should be evaluated at the same time because they are often linked to each other. Thus, in a serum lipid profile, you will measure different blood parameters:
- Total cholesterol: It is the total measure of cholesterol particles in the blood. It does not distinguish between LDL and HDL cholesterol. Thus, it is often taken as a reference to find both. Many risk calculators use total cholesterol instead of LDL, so it is also valuable for medical practice.
- HDL cholesterol: It is also termed good cholesterol because high levels are usually a good sign. This lipoprotein clears the excess cholesterol and other lipids found in the blood vessels and contributes to reversing atherosclerosis.
- VLDL cholesterol: It is a type of cholesterol usually associated with a bad prognosis. Luckily, it is not the most common type, and it is usually not in high levels.
- Calculated LDL cholesterol: After receiving our total cholesterol, HDL, and triglyceride levels, the laboratory calculates LDL cholesterol. This is the so-called “bad” cholesterol because it takes lipids from the liver and spreads them in the arteries. This is also the type of lipoprotein that gets oxidized and creates atherosclerotic plaques.
- Triglycerides: They are essential fatty acids in the blood. What it does is transporting fat particles in a bundle of three, hence the name triglycerides. Triglyceride levels often increase as a result of dietary changes. It is also associated with various comorbidities.
Anyone with signs and symptoms of dyslipidemia should run the blood tests listed above. However, as mentioned above, you may not display high cholesterol symptoms. Familial hypercholesterolemia is an exception because it is associated with extremely high cholesterol levels. Other patients who need to measure their cholesterol levels are people with atherosclerotic disease or a family history of atherosclerosis.
These measurements should be done before taking any food, preferably in the morning before taking breakfast. This way, the results will be more accurate. However, the difference won’t be abysmal if they are measured in the non-fasting state.
If the patient is undergoing active disease, it is better to wait for its resolution. Triglycerides and cholesterol levels decrease in people with ongoing inflammation. Thus, you can get a bad reading if you take the sample while going through the infectious disease.
Another important recommendation is to be careful around myocardial infarction. After an episode of heart attack, the patient’s blood lipid levels are highly variable and inaccurate for up to 30 days. This change in blood lipids starts around 24 hours after the acute episode. Thus, if you take a sample right after the episode or in the emergency room, it is likely accurate.
Depending on your case, the doctor may order additional tests. For example:
- Lp(a): This is a very useful protein in borderline cases or when doctors are not entirely sure if you really need therapy. It is also recommended in cases of premature atherosclerotic disease.
- C reactive protein: As noted above, this protein is an inflammatory marker. It is helpful in the same population as Lp(a). In patients with borderline cases, doctors need additional data to decide on the treatment and in premature atherosclerotic disease.
- Direct LDL cholesterol test: As noted above, most lipid profile exams calculate LDL after receiving total cholesterol, HDL, and triglyceride levels. But if you have very high triglycerides, measuring LDL levels directly in a separate exam will be a better idea.
- Additional testing in newly diagnosed patients: When diagnosed for the first time with dyslipidemia, patients should run additional tests. They include a fasting glucose test, creatinine levels, liver enzymes, urinary protein levels, and thyroid-stimulating hormone. This allows doctors to diagnose a secondary cause of dyslipidemia such as diabetes and thyroid problems.
How can cholesterol levels be monitored?
Monitoring cholesterol levels will be appropriate to evaluate the results of the treatment. If you were recently diagnosed with dyslipidemia, you might need a new measurement a few weeks after starting treatment. This time allows your body to respond to the treatment and lower your cholesterol levels. If they are still high, your doctor may decide to increase the dose of cholesterol-lowering medications or change the treatment strategy.
Monitoring cholesterol levels regularly is also recommended in some patients to diagnose dyslipidemia for the first time. Screening recommendations are different from one medical society to the other. However, they all agree that patients with cardiovascular risk factors should get screened. Especially those with hypertension, diabetes mellitus, a family history of coronary artery disease, and tobacco smokers.
Healthy children are often screened for high cholesterol levels before puberty and after reaching 17 years old. If they have risk factors such as diabetes or high blood pressure, they can be screened at age 2-8 years and then every 1-3 years, depending on the severity of their risk factors.
Dyslipidemia is a modern-world disease, but one we can often control with a healthy diet. We don’t need to wait for symptoms to start doing something about it. The first symptom could be chest pain and a heart attack, and we don’t want that. Other complications include peripheral artery disease, stroke, visual impairments, and even erectile dysfunction.
Screening is easier than waiting for the complications of high cholesterol levels. It is also safer and will save us money and quality of life if we start to do something about it.