Hypercholesteremia Is a Silent Killer

Patients cannot “feel” high cholesterol, and symptoms of the condition often do not present until it is too late.

As a result, millions of Americans do not know that they have high cholesterol until it shows up on a blood test or as a heart attack. Of course, everyone needs cholesterol to survive because it makes vitamin D and other hormones.¹ But a problem can develop when the liver is already producing a sufficient amount of cholesterol and an individual eats an abundance of cholesterol-rich foods. Consuming too much of this essential substance can eventually clog one’s arteries, hardening them over time. That leads to restricted blood flow, which could result in a heart attack.²

Causes of Hypercholesteremia

There are numerous foods that contain large amounts of cholesterol, and when eaten in excess over an extended period of time, they can lead to elevated levels of cholesterol in the body. These foods include butter, cream, eggs, fried foods, red meat, and whole milk.¹ These items can still be consumed but should be done so in moderation. Those seeking to lower their cholesterol should increase their consumption of other foods, such as fresh fruit, vegetables, and whole grains.¹ In addition, living a sedentary lifestyle and being obese can contribute to high cholesterol levels. Drinking plenty of water and exercising daily can help lower cholesterol levels.²

Although lifestyle choices can result in high cholesterol, the condition can also be genetic, caused by what is known as familial hypercholesterolemia.² This inherited disorder can lead to extremely high levels of cholesterol in people starting in their 20s.² Patients who have this disorder are missing the LDLR gene that removes bad cholesterol, or low-density lipoprotein (LDL), from the bloodstream. Without the LDLR gene, these individuals cannot get rid of LDL cholesterol. Therefore, it builds up in the blood, causing even young individuals to be at a high risk for coronary artery disease.²

Treatment

In addition to making lifestyle modifications, individuals with high cholesterol can be prescribed statin therapy to reduce their LDL cholesterol level to below 100 mg/dL.³ Statin therapy is considered the first-line and mainstay therapy when lifestyle modifications do not work to lower a person’s cholesterol levels. Statins work by inhibiting β-hydroxy-β-methylglutaryl—coenzyme A reductase in the liver, which upregulates the LDL receptors to remove cholesterol from the bloodstream.³ Treating someone with a statin has other benefits. Statins also assist with “plaque stabilization, reduction of platelet activation, and reduction of plaque proliferation and inflammation.”³ The principal adverse effects of statin therapy are muscle cramps and weakness. However, patients also report cognitive and memory changes.³

Patients with familial hypercholesteremia have a different treatment regimen than those with noninherited high cholesterol because they either are missing the LDLR gene or have a low-functioning one. These individuals should be advised to make lifestyle changes to decrease the amount of cholesterol in their blood, but many times this is not enough, and they also need to take several cholesterol-lowering medications.² These patients should be prescribed a statin so that cholesterol can be inhibited from being produced in the liver.³ In addition to a statin, these patients will most commonly be prescribed bile-acid-binding resins or cholesterol absorption inhibitors.³ However, often these patients are on proprotein convertase subtilisin/kexin type 9 inhibitors. This class of medications is a monoclonal antibody injection that helps the LDLR gene recycle to the cell surface to decrease the amount of cholesterol in the bloodstream.³

Follow-up

Patients need to have fasting blood tests to check their cholesterol level. It is recommended that they get these blood tests every 5 years after age 20.¹ Starting young helps to identify familial hypercholesteremia. After starting a new therapy, patients will need to repeat their fasting lipid panel in 4 to 12 weeks initially and every 3 to 12 months thereafter to monitor the effectiveness of the prescribed medication(s). Patients must keep in mind that lifestyle modifications and smoking cessation are also key. This combination can help patients achieve a lower cholesterol level and ultimately live a healthier, longer life.

Heather N. Wolf is a PharmD candidate at the University of Kentucky College of Pharmacy in Lexington.

References

• Freeman MW. The Harvard Medical School Guide to Lowering Your Cholesterol. 1st ed. New York, NY: McGraw-Hill Education; 2005.
• Hypercholesterolemia. US National Library of Medicine/Genetics Home Reference website. ghr.nlm.nih.gov/condition/hypercholesterolemia. Published October 16, 2018. Accessed October 16, 2018.
• Trentman TL, Avey SG, Steven, Ramakrishna H. Current and emerging treatments for hypercholesterolemia: a focus on statins and proprotein convertase subtilisin/kexin type 9 inhibitors for perioperative clinicians. J Anesthesiol Clin Pharmacol. 2016;32(4):440-445. doi: 10.4103/0970-9185.194773.