If you’re diagnosed with high cholesterol, will you need to start taking a statin or other medication? Not always.
High cholesterol can affect your cardiac risk, or the chance that you’ll develop heart disease. Other things, including your age, weight, smoking habits, and family history, may affect your cardiac risk, too.
Your doctor will find out your cardiac risk based on your exam, medical history, and tests. This information will help you and your doctor decide how to treat your high cholesterol: with a healthy diet and exercise alone, or with lifestyle changes and medication.
Understanding Cholesterol
Cholesterol is a type of lipid, a fatty, waxy substance in your blood. High amounts of cholesterol can build up inside your arteries. This can clog and narrow your arteries so blood can’t flow easily. Blood clots can form, break away, and cause a stroke or heart attack.
There are two main types of cholesterol:
- Low-density lipoprotein (LDL), or “bad cholesterol.” If your LDL level is too high, you’re at greater cardiac risk. LDL is the cholesterol that clumps up and clogs your arteries.
- High-density lipoprotein (HDL), or “good cholesterol.” More of this cholesterol can clear out LDL cholesterol. That can lower your cardiac risk and protect your heart.
Triglycerides are another kind of blood lipid. They store extra calories from your food that your body can use for energy. Like high cholesterol, high triglycerides can harden your arteries and lead to a heart attack or stroke.
A blood lipid profile test measures your cholesterol and triglycerides. Healthy numbers are:
- Total cholesterol: below 200 milligrams per deciliter (mg/dL)
- LDL cholesterol: less than 100 mg/dL, or less than 70 mg/dL if you have heart disease , diabetes, heart attack, or stroke
- HDL cholesterol: above 60 mg/dL
- Triglycerides: below 150 mg/dL
Types of High Cholesterol
There are different types of high cholesterol, based on what’s causing it:
Familial hypercholesterolemia (FH). It’s when high cholesterol runs in your family. It's a condition related to genetics. You may have very high levels of LDL cholesterol, which puts you at high risk of heart disease, even at a younger age.
A heart-healthy diet, regular exercise, and staying at a healthy weight are part of a good plan to reduce high cholesterol. But lifestyle changes usually aren't enough if you have genetic high cholesterol. You likely will also need to treat it with medications and, sometimes, other approaches.
Treatments for familial hypercholesterolemia include:
- Statins. The most common choices. These pills reduce the amount of cholesterol your body makes and help clear it from your blood.
- PCSK9 inhibitors (Praluent, Repatha). Injected drugs that block a protein to help lower LDL in your blood.
- Inclisiran (Leqvio). Another injected drug that lowers LDL. It works by interfering with production of the same protein targeted by PCSKP inhibitors.
- Bempedoic acid (Nexletol). A pill that works in a similar way to statins and may have fewer side effects for some people.
- Ezetimibe (Zetia). Another cholesterol-lowering pill that can be used alone or in combination with bempedoic acid, in a pill sold as Nexlizet.
- Bile acid sequestrants. Such as cholestyramine or colesevelam, which reduce the cholesterol absorbed by your intestines. These medicines come in pills, powders, and chewable bars.
- LDL apheresis. A dialysis-like procedure you may get every few weeks to remove cholesterol from your blood. It's generally used only if you have severe, hard-to-treat cholesterol problems, such as a rare kind inherited from both parents.
Secondary high cholesterol. This is high cholesterol linked to health conditions like diabetes, heavy drinking, chronic kidney disease, hypothyroidism, and a high-fat diet or lack of exercise. Certain drugs for other medical conditions, like steroids, can cause high cholesterol, too.
Treatments for this kind of high cholesterol can depend on your other risk factors. The most common treatments include:
- Eating a heart-healthy diet rich in fruits, vegetables, and whole grains; low in sugar and saturated fat; and as free as possible from artificial trans fats.
- Exercising regularly
- Quitting smoking
- Losing weight
- Taking medication, starting with statins if lifestyle changes aren’t enough
- Using other medications, such as ezetimibe (Zetia), PCSK9 inhibitors, niacin, fibrates, or omega-3 fatty acid supplements
High triglycerides. You may have high levels of these blood fats with or without high LDL levels. An unhealthy diet, obesity, diabetes, heavy drinking, kidney disease, and hypothyroidism can raise your levels. In some people, high triglycerides run in the family.
Treatment of high triglycerides can include:
- Eating a heart-healthy diet
- Exercising regularly
- Avoiding alcohol
- Losing weight if you’re overweight
- Taking medication, such as nicotinic acid, fibrates, or omega-3 fatty acid supplements
- Using statins if you also have high LDL cholesterol, heart disease, or diabetes
Low HDL cholesterol.Your levels of good cholesterol can drop because of smoking, HIV infection, uncontrolled diabetes, or some kidney problems. Some drugs may lower your HDL as a side effect, including beta-blockers and steroids.
Treatments for low HDL focus on lifestyle changes and include:
- Eating a heart-healthy diet
- Exercising regularly
- Not smoking
- Limiting alcohol
- Taking certain medicines that lower LDL and sometimes raise HDL, such as fibrates or statins (rosuvastatin [Crestor], simvastatin [Zocor]). However, research shows that raising HDL with medicine doesn’t necessarily reduce heart risks.
How to Know if You Need Treatment
Everyone with high cholesterol should start with heart-healthy lifestyle changes like diet, exercise, quitting smoking, and weight loss. But if your cardiac risk is high, you may need treatment with medications, too.
Your doctor can use a formula to calculate a score that shows your risk of a heart attack in the next 10 to 30 years.
Your cardiac risk is based on a combination of these things:
- Total, LDL, and HDL cholesterol
- Blood pressure
- Age
- Race
- Sex
- Smoking habit or past smoking habit
- Diabetes
- Heart disease or family history of early heart disease
You may not need to treat high cholesterol with medications like statins now if you are:
- 19 or younger and don’t have FH
- 20-39, with no family history of early heart disease, and your LDL is below 160 mg/dL
- 40-75, and your cardiac risk is low (less than 5%)
- 40-75, and your cardiac risk is borderline (5% to less than 7.5%)
- 40-75, and your cardiac risk is intermediate (7.5% to less than 20%)
- 75 or older
- Pregnant
- Have advanced liver disease
If your cardiac risk score is borderline or intermediate: Your doctor may talk with you about the risks and benefits of cholesterol-lowering drugs, including side effects.
Ask yourself if you’re ready to stick with a healthy diet, weight loss, and exercise. If you’re not, you may want to treat high cholesterol with medication.
If your cardiac risk is intermediate or unclear, but you’re not sure if you want to take medication to treat your high cholesterol, your doctor may suggest one of these heart disease screening tests:
Coronary calcium scan
A coronary calcium scan is a CT scan that checks for the buildup of plaque that contains calcium in your heart’s arteries. That plaque can harden the arteries. Your heart may not be able to get the blood it needs to work the way it needs to.
A coronary calcium scan can assess your risk of coronary artery disease (CAD) before you have any signs or symptoms. This scan can help your doctor tell if you need cholesterol medications or just lifestyle changes to prevent a heart attack.
High-sensitivity CRP
A high-sensitivity C-reactive protein blood test, or hs-CRP, checks for inflammation.
It can measure your heart disease risk to help you and your doctor decide if you need to start treatment. If your hs-CRP is more than 3.1 milligrams per liter (mg/L), then your actual risk of heart disease may be higher than your cardiac risk score suggests. This test can also predict your risk of a second heart attack if you’ve already had one.
