High cholesterol

Disease Description (Causes and Symptoms)

• Definition: Hypercholesterolemia is a condition in which excess cholesterol in the blood, particularly LDL cholesterol, is deposited in the arterial walls and promotes atherosclerosis.
• Causes and pathophysiology:
  • Genetic factors: Genetic defects, such as familial hypercholesterolemia, cause problems with LDL production and removal.
  • Lifestyle factors: Excessive intake of saturated fat and dietary cholesterol from animal sources, overweight or obesity, insufficient physical activity, excessive alcohol consumption, and smoking.
  • Other diseases and medications: Diabetes, hypothyroidism, nephrotic syndrome, oral contraceptives, steroids, and others.
  • Age and sex: Levels are relatively higher in men than in premenopausal women and tend to increase with age.
  • Pathophysiology: Increased blood LDL → accumulation in the vascular intima and plaque formation → increased risk of ischemic heart disease (angina and myocardial infarction) and stroke due to narrowing of the vessel lumen and plaque rupture.
• Main symptoms:
  • Generally asymptomatic (a metabolic disease). Symptoms usually appear only when complications of atherosclerosis occur, such as chest pain, shortness of breath, syncope, or stroke symptoms.
• Diagnostic summary:
  • A lipid panel (total cholesterol, LDL-C, HDL-C, and triglycerides) through fasting blood collection (usually 9–12 hours). Regular testing is recommended for adults (≥20 years).

Treatment Methods (Standard Treatment, Medications, Lifestyle Management, and Precautions)

• Treatment principles:
  • The target LDL level and treatment intensity are determined according to cardiovascular risk (lifestyle therapy is prioritized for low-risk groups, while lower targets and active drug treatment are recommended for high-risk groups).
  • For low-risk groups, reassessment is performed after 3–6 months of non-drug treatment (lifestyle modification).
• Non-drug treatment (basic for all patients):
  • Diet: Reduce saturated and trans fats and increase intake of unsaturated fats (vegetable oils and fish), dietary fiber, vegetables, and fruit. Limit processed foods and high-fat meat.
  • Weight management: Maintain a standard body weight (weight loss reduces triglycerides and increases HDL).
  • Exercise: Moderate-intensity aerobic exercise each week (for example, at least 150 minutes) is recommended.
  • Stop smoking and reduce alcohol consumption (or limit alcohol intake).
• Drug treatment:
  • First-line: Statins — strongly reduce LDL and reduce the risk of cardiovascular events. Their effects in improving blood lipid levels and protecting the cardiovascular system have been verified.
  • Additional or alternative medications: Ezetimibe, PCSK9 inhibitors (for high-risk or familial cases or when statins are insufficient), bile acid sequestrants, and, when necessary, niacin and fibrates (primarily to improve triglycerides).
  • In familial hypercholesterolemia, consider active treatment from childhood and referral to a specialized clinic.
• Monitoring and precautions:
  • Liver function tests (liver enzymes) before and during treatment; CK testing is recommended if necessary when muscle symptoms occur.
  • When taking statins, beware of drug interactions, particularly CYP3A4 inhibitors and some antibiotics, antifungals, and antivirals.
  • Statins are contraindicated during pregnancy and breastfeeding → if pregnancy is planned, consult a doctor to adjust medications.
  • Consult a doctor immediately if abnormal symptoms such as muscle pain or muscle weakness occur.
• Risk of complications:
  • If left untreated or risk factors are not controlled, the risk of cardiovascular complications such as coronary artery disease (angina and myocardial infarction) and ischemic stroke increases.

Outpatient Visit Checklist (Including Preparation Items and Example Questions)

• Items to bring/preparations:
  • List of medications and health functional foods currently being taken (including dosage and time of administration)
  • Previous blood lipid test results (documents if possible)
  • Family history information (whether parents or siblings have had coronary artery disease, stroke, or longstanding high cholesterol, and their ages)
  • Records of weight changes and changes in exercise and eating habits, as well as smoking and alcohol use
  • Existing diseases (diabetes, thyroid disease, kidney disease, etc.) and currently prescribed medications
  • Maintain fasting before the test (usually 9–12 hours) — confirm fasting if a lipid test is scheduled at the outpatient visit
• Information to tell the doctor in advance during the outpatient visit (examples):
  • “I have recently taken medications, particularly steroids, contraceptives, or antivirals.”
  • “Someone in my family had a myocardial infarction at a young age or had very high cholesterol (coronary artery disease at a young age).”
  • “I have a history of muscle pain or liver disease.”

General Example Questions to Ask the Doctor

• “What is my target LDL cholesterol level? How is it determined according to my risk?”
• “What are the common side effects of taking statins, and what should I do if they occur?”
• “What specifically should I change in my lifestyle, such as my diet and exercise?”
• “How often should I undergo testing, such as lipid and liver function tests?”
• “I am planning a pregnancy. How should drug treatment be managed?”

Examples of Disease-Specific Questions

• “A family member had a myocardial infarction at a young age. Should I be tested for familial hypercholesterolemia (whether it is hereditary)? Do I need genetic testing or referral to a specialized clinic?”
• “Could you explain my target LDL level based on my individual cardiovascular risk, such as my 10-year risk, given my current LDL level, and when I should start medication?”