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 dizziness. Just silent buildup-fatty deposits creeping through your arteries, slowly narrowing the path for blood to reach your heart and brain. By the time symptoms show up, it’s often because a clot has formed, or an artery is already blocked. That’s why knowing about hypercholesterolemia isn’t just helpful-it’s life-saving.

What Exactly Is Hypercholesterolemia?

Hypercholesterolemia means your blood has too much cholesterol. Cholesterol itself isn’t bad. Your body needs it to build cells, make hormones, and digest food. But when levels get too high-especially the kind called LDL, or "bad" cholesterol-it starts sticking to artery walls. Over time, that builds up into plaque. Plaque hardens, narrows arteries, and can break off to trigger a heart attack or stroke.

The numbers matter. The American Heart Association says total cholesterol above 200 mg/dL is considered elevated. But what really counts is your LDL level. If it’s above 190 mg/dL, that’s classified as severe hypercholesterolemia. Even levels between 130 and 159 mg/dL can be dangerous if you have other risk factors like high blood pressure, diabetes, or a family history of early heart disease.

Familial vs. Acquired: Two Very Different Causes

Not all high cholesterol is the same. There are two main types: genetic (familial) and lifestyle-related (acquired).

Familial hypercholesterolemia (FH) is inherited. One faulty gene from a parent can send LDL levels soaring from birth. About 1 in 250 people have this condition, but most don’t know it. People with heterozygous FH-meaning they got the gene from one parent-often have LDL levels between 190 and 400 mg/dL. Those with homozygous FH, who got it from both parents, can have levels over 450 mg/dL. These individuals are at extreme risk: untreated, they can have heart attacks before age 20.

Physical signs can hint at FH. Yellowish fatty deposits around the eyelids (xanthelasmas) or thickened tendons in the heels or knuckles (tendon xanthomas) are telltale markers. If you or a close relative has these, get tested-even if you’re young.

Acquired hypercholesterolemia, on the other hand, comes from what you eat, how active you are, or other health problems. Poor diet, lack of exercise, obesity, smoking, and excessive alcohol all contribute. Medical conditions like hypothyroidism, chronic kidney disease, and type 2 diabetes also raise cholesterol. Some medications, like certain diuretics or steroids, can nudge levels up too.

Why It’s Silent-And Why That’s Dangerous

Dr. Roger Blumenthal from Johns Hopkins puts it bluntly: "High cholesterol is a silent killer." You won’t feel it until your arteries are 70% blocked. That’s why routine screening is non-negotiable. The U.S. Preventive Services Task Force recommends a lipid panel for all adults between 40 and 75. But if you have a family history of early heart disease, or if you’re overweight or diabetic, you should get tested even earlier-even in your 20s.

And here’s something many don’t realize: fasting isn’t required anymore for basic cholesterol tests. You can walk in, get blood drawn, and get results without skipping breakfast. That makes checking your numbers easier than ever.

How High Is Too High? The Numbers That Matter

Let’s break down what your numbers mean:

• Total cholesterol: Below 200 mg/dL is ideal. 200-239 is borderline high. 240+ is high.
• LDL (bad cholesterol): Below 100 mg/dL is optimal. 100-129 is near optimal. 130-159 is borderline high. 160-189 is high. 190+ is very high.
• HDL (good cholesterol): Above 60 mg/dL is protective. Below 40 for men or 50 for women is a risk factor.
• Triglycerides: Below 150 mg/dL is normal. Above 200 is high.

These aren’t just numbers on a page. For every 39 mg/dL drop in LDL, your risk of a heart attack or stroke drops by 22%. That’s the power of lowering cholesterol.

How Is It Treated? From Diet to Drugs

First step: lifestyle changes. For many, especially those with acquired hypercholesterolemia, diet and exercise alone can cut LDL by 10-15%. The Portfolio Diet-rich in plant sterols, oats, nuts, soy, and fiber-has been shown in clinical trials to reduce LDL by nearly 30%. But sticking to it is hard. Only about half of people keep it up past a year.

If lifestyle isn’t enough, medication kicks in. Statins are the first-line treatment. Drugs like atorvastatin and rosuvastatin can slash LDL by 50% or more. They’re safe, well-studied, and proven to save lives. But some people can’t tolerate them-about 7-29% experience muscle pain or other side effects.

For those people, or for those with FH, other options exist:

• Ezetimibe: Blocks cholesterol absorption in the gut. Lowers LDL by about 18%.
• PCSK9 inhibitors: Injectable drugs like alirocumab and evolocumab. They can drop LDL by another 50-60% on top of statins.
• Inclisiran (Leqvio): A newer shot given just twice a year. It works at the genetic level to reduce LDL production. A game-changer for adherence.

People with FH often need all three: a high-dose statin, ezetimibe, and a PCSK9 inhibitor. That’s not over-treatment-it’s survival.

Why So Many People Aren’t Getting Help

Here’s the ugly truth: even though we have effective treatments, most people with high cholesterol aren’t getting them. In the U.S., only 55.5% of adults who should be on statins are actually taking them. Among Black adults, the rate drops to 42.3%. Women are less likely to be prescribed statins than men, even when their risk is the same.

Why? A mix of things. Some don’t know they have it. Others don’t feel sick, so they skip meds. Some worry about side effects. Others can’t afford them-even though many generics cost less than $10 a month.

And the cost of doing nothing? The American Heart Association estimates cholesterol-related heart disease costs the U.S. $218 billion a year. That’s $142 billion in medical bills and $76 billion lost to missed work and early death.

What’s New? The Future of Cholesterol Management

The field is moving fast. Genetic testing is becoming more accessible. Polygenic risk scores can now identify people who have high cholesterol not from one gene, but from dozens of small genetic tweaks-people who might need earlier intervention than we used to think.

Also, tools like digital reminders, apps that track diet and meds, and telehealth follow-ups are helping people stick to treatment. And new guidelines are clearer: for very high-risk patients, doctors are now aiming for LDL below 55 mg/dL-not just "lowering it by 50%".

The big challenge ahead? Obesity. As more people become overweight or obese, secondary hypercholesterolemia is rising. By 2030, half of U.S. adults could be obese. That means more diabetes, more inflammation, more clogged arteries.

What You Can Do Right Now

You don’t need a PhD to take control. Here’s what works:

1. Get tested. If you’re 40 or older, ask for a lipid panel. If you have risk factors, get tested sooner.
2. Know your numbers. Write them down. Understand what LDL means for you.
3. Move more. Even 30 minutes of brisk walking five days a week helps.
4. Eat smarter. Swap butter for olive oil. Choose whole grains over white bread. Add beans, oats, nuts, and fatty fish to your meals.
5. Talk to your doctor. If your LDL is high, don’t wait. Ask about statins. Ask about other options. Don’t assume you can "just eat better."

High cholesterol isn’t your fault. But managing it? That’s your power. You can’t change your genes. But you can change your next blood test. And that’s enough to keep you alive longer, healthier, and free from the fear of a heart attack.