High Cholesterol: What You Need to Know About Hypercholesterolemia

Most people don’t feel high cholesterol until it’s too late. There’s no pain, no warning sign, no sudden ache. Just a quiet buildup in your arteries, year after year, silently narrowing the roads that carry blood to your heart and brain. By the time symptoms show up-chest pain, shortness of breath, or worse-it’s often already damaged something critical. That’s why hypercholesterolemia, the medical term for abnormally high cholesterol in the blood, is called a silent killer. And it’s not rare. In the U.S. alone, 94 million adults have total cholesterol above 200 mg/dL, according to the CDC. That’s nearly 1 in 3 people.

What Exactly Is Hypercholesterolemia?

Hypercholesterolemia means your blood has too much cholesterol, especially the bad kind-low-density lipoprotein, or LDL. Cholesterol isn’t all bad. Your body needs it to build cells, make hormones, and digest food. But when LDL levels climb too high, it sticks to artery walls, forming plaques. These plaques harden over time, making arteries stiff and narrow. That’s atherosclerosis. And it’s the leading cause of heart attacks and strokes worldwide.

There are two main types: familial (genetic) and acquired (lifestyle-driven). Familial hypercholesterolemia (FH) is inherited. If one parent has it, you have a 50% chance of getting it. About 1 in 250 people globally have this form, and many don’t even know it until they have a heart attack in their 30s or 40s. In contrast, acquired hypercholesterolemia comes from diet, inactivity, obesity, or other conditions like diabetes or hypothyroidism. It’s more common, and often more preventable.

How Do You Know If You Have It?

You can’t feel it. You can’t see it. The only way to know is through a simple blood test-a lipid panel. This test measures total cholesterol, LDL (bad), HDL (good), and triglycerides. The 2018 AHA/ACC guidelines say:

• Optimal LDL: under 100 mg/dL
• Borderline high: 130-159 mg/dL
• High: 160-189 mg/dL
• Very high: 190 mg/dL or above

Severe cases-especially with FH-can push LDL above 400 mg/dL. That’s not just risky. It’s dangerous. People with untreated FH are 20 times more likely to have a heart attack before age 40 than those without it.

Physical signs can hint at FH: fatty lumps on tendons (tendon xanthomas), especially on the heels or knuckles, or yellowish patches around the eyelids (xanthelasmas). These aren’t common, but if you see them, get tested. They’re red flags.

Familial vs. Acquired: The Big Difference

Not all high cholesterol is the same. Familial hypercholesterolemia starts at birth. Your liver can’t clear LDL properly because of a gene mutation-usually in the LDLR or PCSK9 gene. Even if you eat salad and run marathons, your LDL stays high. That’s why FH patients often need three drugs at once: a high-dose statin, ezetimibe, and a PCSK9 inhibitor like alirocumab.

Acquired hypercholesterolemia is different. It’s usually tied to what you eat, how much you move, and other health issues. Eating too many saturated fats-found in red meat, butter, full-fat cheese-raises LDL. Being overweight, especially with belly fat, lowers HDL and raises triglycerides. Diabetes and hypothyroidism also mess with cholesterol metabolism. The good news? This kind often responds to lifestyle changes. The Portfolio Diet, which includes oats, nuts, plant sterols, and soy, has been shown to lower LDL by 15-30% in clinical trials.

Why It’s Not Just About Diet

For years, we were told to avoid eggs and shellfish because they’re high in cholesterol. But that’s outdated. The Dietary Guidelines for Americans removed the daily cholesterol limit in 2020. Why? Because for most people, dietary cholesterol has a small effect on blood cholesterol. What matters more is saturated and trans fats. Those are the real culprits.

Still, there’s debate. A 2019 JAMA Internal Medicine study found that every extra 300 mg of dietary cholesterol per day (about two eggs) was linked to a 17% higher risk of heart disease. So while eggs aren’t the enemy for everyone, if you already have high cholesterol, it’s smart to be cautious.

Other hidden triggers: certain medications. Thiazide diuretics (used for high blood pressure) can raise LDL by 10-15%. Beta-blockers and some steroids can also nudge cholesterol up. If you’re on meds and your numbers worsened after starting them, talk to your doctor. It’s not always the food.

Treatment: It’s Not Just Statins

Statins are still the first-line treatment. Drugs like atorvastatin and rosuvastatin can cut LDL by 50% or more. But they’re not perfect. Between 7% and 29% of people can’t tolerate them because of muscle pain or liver issues. That’s where alternatives come in.

• Ezetimibe: Blocks cholesterol absorption in the gut. Lowers LDL by about 18%.
• PCSK9 inhibitors (alirocumab, evolocumab): Injected every 2-4 weeks. Can drop LDL by another 50-60% on top of statins.
• Inclisiran (Leqvio): A newer shot given just twice a year. It silences a gene that makes PCSK9, so your liver clears LDL better. It’s a game-changer for people who struggle with daily pills.

For FH patients, doctors often start with a triple combo: high-intensity statin + ezetimibe + PCSK9 inhibitor. It’s aggressive, but necessary. Without it, many won’t reach the target LDL below 70 mg/dL.

Why People Don’t Stick With Treatment

Even with effective drugs, most people don’t take them long-term. CVS Health found that only half of statin users are still taking them after one year. Why? Side effects, forgetfulness, or thinking they’re fine because they feel okay. But high cholesterol doesn’t make you feel bad until it’s too late.

Adherence drops even more with lifestyle changes. The Portfolio Diet works-but only 45% of people stick with it after a year. It’s hard to give up cheese, butter, and fried foods. And if you’re not seeing immediate results, motivation fades.

That’s why digital tools are becoming more important. Apps that track meals, remind you to take pills, and connect you with dietitians are helping. Some insurers now cover nutrition counseling for high-risk patients. It’s not magic, but it helps.

The Cost of Doing Nothing

High cholesterol isn’t just a health problem-it’s an economic one. In 2023, heart disease linked to high cholesterol cost the U.S. $218 billion. $142 billion went to hospital stays, meds, and doctor visits. The rest? Lost wages, early retirement, caregivers missing work.

And the gaps are glaring. Only 55.5% of eligible U.S. adults get statins. Among Black adults, it’s just 42.3%. Women are less likely than men to be prescribed them, even when they have the same risk profile. This isn’t about access alone-it’s about awareness, bias, and how little we talk about cholesterol until it’s an emergency.

What You Can Do Today

You don’t need to overhaul your life overnight. Start small:

• Get a lipid panel if you’re 40 or older-or younger if you have a family history of early heart disease.
• Swap butter for olive oil. Choose lean proteins like chicken, fish, or beans over red meat.
• Add 30 minutes of walking most days. It doesn’t have to be intense. Just consistent.
• Read food labels. Avoid anything with “partially hydrogenated oil” or more than 2g of saturated fat per serving.
• If you’re on meds, don’t skip doses. Talk to your doctor before stopping, even if you feel fine.

And if you’ve been told you have high cholesterol? Don’t panic. Don’t wait. You’re not alone. And you’re not powerless. With the right plan, you can lower your risk significantly-even if you have FH.

What’s Next for Cholesterol Management?

The future is getting smarter. Polygenic risk scores-based on dozens of genetic markers-can now identify people at high risk even if their LDL isn’t sky-high yet. This lets doctors intervene earlier, before plaques form.

Also, new guidelines are pushing for stricter targets. The European Society of Cardiology now says very high-risk patients (like those with FH or diabetes) should aim for LDL under 55 mg/dL. That’s lower than ever before. And with inclisiran and other gene-targeted therapies, hitting that target is becoming possible for more people.

But the biggest challenge isn’t science-it’s action. We know how to treat this. We have the tools. What’s missing is the will-to get tested, to take meds, to change habits. Because when it comes to high cholesterol, the most powerful medicine isn’t a pill. It’s awareness.