Patient Information

Cholesterol comes from two sources, production by cells in our body and diet. Inherited genetic conditions often cause very high cholesterol levels from birth, independent of a persons weight and diet. Eating processed foods, saturated fats and cholesterol containing foods can also cause elevated cholesterol.

Other risk factors for high cholesterol include:

• Kidney and liver disease
• Diabetes and Obesity
• ​Smoking
• Lack of physical activity
• Poor Diet
• Genetic (inherited) factors
• ​Medications
• Hormones (testosterone, oestrogen, pill)

While small amounts of cholesterol are essential for cells in our body, elevated cholesterol often leads to plaque build up in arteries, especially if levels are very high and also if other risk factors such as high blood pressure, smoking and diabetes are present. These plaques can rupture and cause a heart attack or stroke. If cholesterol is elevated from birth as is seen in inherited conditions such as familial hypercholesterolemia, it often leads to early cardiovascular disease.

Low-density lipoprotein (LDL) is often referred to as the ‘bad’ cholesterol  because it ends up in arteries causing cholesterol deposits and blockages. LDL is the main target in patients with increased CV risk and can be lowered very effectively and safely with medication.

High-density lipoprotein (HDL) is often referred to as the ‘good’ cholesterol because it transports cholesterol from cells back to the liver, where it is excreted into the bile and the faeces.

Lipoprotein (a) or Lp(a) is often referred to as ‘ ugly’ cholesterol and one of the strongest risk factors for CV disease. Like LDL, high levels of Lp(a) can stick in your artery wall. Elevated Lp(a) is often inherited.

Trglycerides (TG) are another fat in the body. Storage fat such as abdominal fat contains TG. TG are often increased in diabetes, obesity, smokers and people who have a diet rich in saturated fat. They can also be elevated in patients with inherited lipid disorders. If TG are very high (> 10 mmol/L) they can cause pancreatitis, a very painful inflammation of the pancreas. Elevated TG also increase risk of cardiovascular disease.

People with elevated cholesterol generally don’t have symptoms, and a heart attack is often the first manifestation. Some people with inherited conditions that lead to very high cholesterol have cholesterol deposits on their eye lids, achilles tendons and elbows.

High cholesterol is often detected as part of a Heart Health Check via your GP. If you have a family history of high cholesterol (parents or siblings have had a heart attack or stroke before age 55), speak to your GP about your heart disease risk.

Cholesterol is measured by various laboratories doing a blood test called a lipid profile. A cholesterol test usually involves having your blood drawn from a vein in your arm. The test can help determine your risk of heart disease and stroke.

Once your GP or specialist has determined that your CV risk is high and your cholesterol needs to be lowered, there are several ways to achieve this.

Diet

Some foods (such as butter) are higher in cholesterol than others, or they may contain ingredients that can contribute to high cholesterol such as saturated fats. Decreasing cholesterol in your diet does not always work enough as the body often simply produces more cholesterol if dietary intake is reduced.

It is often difficult to lower cholesterol with diet alone, especially if levels are very high or in patients who already have heart disease. Following a heart healthy diet that contains lots of vegetables, whole grains, fibre, soy and plant sterols can help lower your cholesterol.

One of the most effective diets to lower cholesterol is the Portfolio Diet, that has been developed specifically for people with elevated cholesterol levels.

Nutraceuticals:
Plant Sterols, are natural ingredients of plants and look like cholesterol. They are absorbed instead of cholesterol and then excreted again into the bile since the body cannot utilize them. Plant sterols can be found in margarines such as benechol, logichol or enriched dairy products and cereals or supplements and can help lower cholesterol by up to 10%.
Soy products such as tofu and soy milk can also help lower cholesterol.
Fibre, in the form of psyllium husk or oats for example can also help lower cholesterol.
Fish oil (omega 3 fatty acids) is effective in lowering triglycerides and can also have an effect on lowering cholesterol in people with high triglycerides.

Medications

In patients who have had a heart attack or stroke or who have very high cholesterol levels, medication is often necessary to prevent plaque buildup in arteries. Cholesterol medications are generally very safe and effective.

Statins
Stains such as atorvastatin or rosuvastatin are the most common medications to lower cholesterol. They prevent the production of cholesterol in the body by inhibiting an enzyme that is responsible for cholesterol production and can lower cholesterol by up to 50%. They have been shown to prevent heart attacks and strokes in many trials.

Ezetimibe
Ezetimibe (ezetrol) is a cholesterol absorption inhibitor that prevents the body from reabsorbing cholesterol in the intestine. They work a bit like plant sterols but are more effective and better tolerated. Ezetimibe works very well in conjunction with statins and can lower cholesterol by up to 30% by itself or 70% with statins.

PCSK9 Inhibitors
PCSK9 inhibitors such as Repatha are a new class of cholesterol drugs that are injected subcutaneously and very effective. They can lower cholesterol by up to 70%. They are monoclonal antibodies that allow the liver to excrete cholesterol more effectively by increasing LDL receptors. They are mainly used in people with very high cholesterol levels, who do not achieve low LDL levels with statins and ezetrol alone.

Fibrates
Fibrates such as fenofibrate are mainly used in patients with high triglycerides, especially in diabetics. They also have a small effect on cholesterol.

Familial hypercholesterolaemia (FH) is a dominantly inherited disorder present from birth that markedly elevates plasma low-density lipoprotein (LDL) cholesterol and causes premature coronary heart disease. There are at least 20 million people with FH worldwide, but the majority remain undetected and current treatment is often suboptimal.

For more information please visit the FH Australasia Network