High Cholesterol
High Cholesterol: A Complete Patient Guide
Cholesterol is a fatty substance made by the liver and found in some foods. You need some of it to build cells and hormones, but too much LDL (“bad”) cholesterol in the blood gradually builds up in the artery walls as plaque. Over years this narrows the arteries and raises the risk of heart attack, stroke and circulation problems.
High cholesterol causes no symptoms, so it is usually found by a blood test. It is very common in the UK, and it is one of the most treatable risk factors for heart disease. What matters most is not one number on its own but your overall cardiovascular risk, which combines cholesterol with age, blood pressure, smoking, diabetes, family history and existing heart disease.
Cholesterol is influenced by diet, weight, alcohol, inactivity, thyroid, kidney and liver conditions and some medicines, but also strongly by genes. Familial hypercholesterolaemia (FH) is an inherited condition causing very high cholesterol from birth, and it is under-diagnosed. Another inherited risk factor, lipoprotein(a), is raised in about one in five people and is measured once in a lifetime.
The European (ESC/EAS) and NICE guidelines recommend lowering LDL cholesterol more intensively in people at higher risk, and treatment, with lifestyle change and usually a statin, is safe and effective for most people.
High cholesterol does not cause symptoms, and there is no way to tell your level by how you feel. This is why testing matters.
When cholesterol causes problems
Chest pain or breathlessness on effort from narrowed heart arteries (angina)
Heart attack or stroke, sometimes as the first sign
Leg pain on walking that eases with rest (peripheral arterial disease)
Signs that may suggest an inherited cause (FH)
Yellowish fatty deposits around the tendons (such as the Achilles tendon or knuckles) or the eyelids (xanthelasma)
A pale ring around the cornea of the eye at a young age
Very high cholesterol, or heart disease at a young age in the family
Cholesterol levels are the result of what you inherit and how you live. Often more than one factor is involved.
Lifestyle and medical causes
A diet high in saturated and trans fats, being overweight, and lack of exercise
Excess alcohol and smoking (which also lower “good” HDL cholesterol)
Type 2 diabetes, an underactive thyroid, kidney or liver disease, and pregnancy
Some medicines, including certain steroids, diuretics and HIV or immune medicines
Inherited causes
Familial hypercholesterolaemia affects roughly 1 in 250 people. LDL cholesterol is high from birth, and untreated it can cause heart disease in the 30s to 50s. It is passed on in families, so relatives should be tested.
Raised lipoprotein(a) is largely genetic and is not changed much by diet. It adds to cardiovascular risk.
Who should be tested
Adults offered NHS Health Checks, people with heart disease, diabetes, high blood pressure or kidney disease, those with a family history of early heart disease or high cholesterol, and anyone with the signs above.
Because cholesterol is silent, the main reason to see a doctor is to be tested and to know your risk.
Arrange an assessment if:
You have never had your cholesterol checked and are over 40, or younger with risk factors
A close relative had a heart attack or stroke young, or has very high cholesterol
Your cholesterol is high and you want to understand your risk and the best treatment
You have side effects from a statin or are unsure whether to take one
You have tendon lumps, eyelid deposits or a very high reading
Call 999 immediately if you have:
Chest pain or pressure lasting more than 15 minutes, or with sweating or breathlessness
Face drooping, arm weakness or slurred speech (stroke)
Diagnosis is by a simple blood test, and a full assessment looks at your overall risk and any hidden disease.
1. Lipid profile
A blood test, usually non-fasting, measures total cholesterol, LDL, HDL, triglycerides and non-HDL cholesterol. Your doctor may also check lipoprotein(a) once, and thyroid, kidney, liver function and blood sugar to look for causes.
2. Cardiovascular risk assessment
Your risk of a heart attack or stroke is calculated from age, sex, blood pressure, smoking, diabetes, cholesterol and other factors (in the UK, QRISK3). Treatment targets depend on this risk rather than the cholesterol number alone.
3. Looking for inherited disease
Very high LDL cholesterol (typically above 4.9 mmol/L), a strong family history or tendon deposits prompts assessment for familial hypercholesterolaemia, which may include genetic testing and testing of relatives.
4. Tests for heart disease
In people at higher risk or with symptoms, an ECG, echocardiogram, CT coronary angiography (which can show plaque and calcium score) or stress echo may be used to look for coronary disease.
Treatment starts with lifestyle changes, and most people at raised risk also benefit from a cholesterol-lowering medicine.
Lifestyle
A Mediterranean-style diet with more vegetables, fruit, pulses, wholegrains, nuts, oily fish and olive oil, and less saturated fat, processed meat and sugar
Regular exercise, a healthy weight, no smoking and moderate alcohol
Foods containing plant sterols or soluble fibre can modestly reduce LDL
Statins
Statins (such as atorvastatin, rosuvastatin) are the first-line treatment. They reduce LDL cholesterol substantially and cut the risk of heart attack and stroke in proportion to the fall in LDL. NICE recommends offering high-intensity atorvastatin to people with established cardiovascular disease and to those at raised risk. Most people tolerate statins well, and serious side effects are rare.
Additional medicines
Ezetimibe blocks absorption of cholesterol in the gut and is often added to a statin
Bempedoic acid is an option for people who cannot take statins
PCSK9 inhibitors (injections such as evolocumab and alirocumab) and inclisiran produce large further reductions in LDL for people with very high cholesterol or established disease who need more than tablets
Targets
The 2019 ESC/EAS guideline recommends an LDL target of below 1.4 mmol/L (and at least a 50% reduction) for those at very high risk, with less strict targets for lower risk groups. NICE advises aiming for at least a 40% reduction in non-HDL cholesterol. Your cardiologist will set a target for you.
Take your medicine as prescribed. Statins work only while you take them, and stopping brings cholesterol back up.
Repeat blood tests, usually 3 months after starting or changing treatment and then yearly, to check the effect and liver tests.
If you get muscle aches, do not just stop. Tell your doctor, as true statin intolerance is less common than people expect, and a different statin, a lower dose or an alternative can usually be found.
Keep active and eat well – lifestyle makes your medicine work better.
Treat other risks: blood pressure, diabetes, weight and smoking.
Check your family. If you have FH, close relatives, including children, should be offered testing.
Information and support: HEART UK, the British Heart Foundation and the NHS.
The lower your LDL cholesterol and the longer it is kept low, the lower your lifetime risk of heart attack and stroke.
For most people, lifestyle and a statin bring cholesterol into a healthy range and substantially reduce risk.
For people with familial hypercholesterolaemia, starting treatment early restores life expectancy close to normal.
Cholesterol is a lifelong issue for most people, and treatment is long-term, but it is generally straightforward and well tolerated.
Existing plaque can often stabilise with intensive treatment, reducing the chance of events.
High cholesterol has no symptoms and is found by a blood test.
Too much LDL cholesterol builds plaque in the arteries, raising the risk of heart attack and stroke.
Your overall cardiovascular risk guides treatment, not the cholesterol number alone.
Familial hypercholesterolaemia affects about 1 in 250 people and runs in families.
Lipoprotein(a) is an inherited risk factor worth measuring once in a lifetime.
Statins are first-line, safe and effective for most people.
Ezetimibe, bempedoic acid, PCSK9 inhibitors and inclisiran provide further lowering when needed.
A Mediterranean-style diet, exercise and not smoking all help.
Do not stop a statin for muscle aches without discussing it first.
Guidelines and sources
This page follows current UK and European guidance:
NICE NG238: Cardiovascular disease: risk assessment and reduction, including lipid modification.
Mach F et al. 2019 ESC/EAS Guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk. European Heart Journal 2020;41:111-188.
These are the questions patients most often ask about cholesterol.
What is a high cholesterol level?
There is no single cut-off, because the right level depends on your overall risk. In general, a total cholesterol above 5 mmol/L or LDL above 3 mmol/L is considered raised for healthy adults, while people with heart disease or diabetes need much lower LDL levels.
What are the symptoms of high cholesterol?
None, in most people. It is found by a blood test. Fatty deposits on tendons or eyelids can occasionally be visible in inherited forms.
What causes high cholesterol?
A diet high in saturated fat, being overweight, inactivity, alcohol, diabetes, an underactive thyroid, kidney disease and some medicines, plus genes. Familial hypercholesterolaemia causes very high cholesterol from birth.
How do I lower my cholesterol?
Eat a Mediterranean-style diet, exercise, lose excess weight, stop smoking and, if you are at raised risk, take a statin. Medicines such as ezetimibe or injections can be added if needed.
Do I have to take a statin for life?
Usually, if you need one. Cholesterol rises again when it is stopped. The decision depends on your risk, and your cardiologist will review it with you.
Are statins safe? What about muscle pain?
Statins are safe and well tested, and serious side effects are rare. Muscle aches occur in a minority, and in trials many such symptoms are not caused by the statin itself. If they occur, a different statin, lower dose or alternative medicine often works.
What is familial hypercholesterolaemia?
An inherited condition causing very high LDL cholesterol from birth. It affects about 1 in 250 people, raises the risk of early heart disease and responds well to treatment. Relatives should be tested.
What is lipoprotein(a), and should I be tested?
Lipoprotein(a) is an inherited cholesterol particle that raises the risk of heart disease and aortic valve disease. It is largely unaffected by diet, and guidelines suggest measuring it once in every adult. If it is high, other risk factors are treated more aggressively.
Can I get a private cholesterol and heart risk assessment?
Yes. A telephone, video or face-to-face consultation in Peterborough or Corby can review your results and calculate your risk, and tests such as CT coronary angiography or ECG can be arranged if needed.
- What is my overall cardiovascular risk, not just my cholesterol?
- What is my LDL target?
- Do I need a statin or additional medicine?
- Should I be tested for familial hypercholesterolaemia or lipoprotein(a)?
- Do I need a heart scan such as a CT calcium score or angiogram?
- What should I do if I get side effects?
- Which foods and exercise make the biggest difference?
- Should my family be tested?
- When should my cholesterol be rechecked?
- Are other conditions, such as diabetes, thyroid or kidney disease, raising my cholesterol?
Cholesterol plaque builds up in the artery wall and narrows the artery over time.
Image: National Heart, Lung, and Blood Institute (NHLBI), Atherosclerosis diagram, Wikimedia Commons. Public domain.
Where cholesterol goes wrong
LDL cholesterol carries cholesterol into the artery wall, where it builds plaque. Lower is better.
HDL cholesterol helps remove cholesterol, but raising it with medicines has not been shown to reduce events.
Triglycerides are blood fats that rise with alcohol, sugar, excess weight and diabetes.
Lipoprotein(a) is a genetically determined particle that adds to risk independently of other levels.
If you have high cholesterol, a family history of early heart disease or want to understand your heart risk, you may benefit from a telephone consultation or video consultation, or a face-to-face consultation in Peterborough or Corby for a more comprehensive assessment.
Investigations such as ECG, echocardiography and CT coronary angiography may be recommended to assess your heart.
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Medically reviewed by Dr Salam Salloum, Consultant Cardiologist. Last updated: . This page is for general information and does not replace personal medical advice.