Hypercholesterolemia

Florian Tiefenböck studied human medicine at the LMU Munich. In March 2014, he joined as a student and has supported the editorial team with medical articles ever since. After receiving his medical license and practical work in internal medicine at the University Hospital Augsburg, he has been a permanent member of the team since December 2019 and, among other things, ensures the medical quality of the tools.

More posts by Florian Tiefenböck All content is checked by medical journalists.

If you have hypercholesterolemia, you have high blood cholesterol levels. Hypercholesterolemia is one of the disorders of lipid metabolism. There are many causes of high cholesterol levels. Vascular calcification is a dangerous consequence. It can lead to serious heart disease such as a heart attack. To treat hypercholesterolemia, sufferers should change their lifestyle, seek treatment for causes, and eliminate risk factors. Read everything you need to know about hypercholesterolemia here.

ICD codes for this disease: ICD codes are internationally recognized codes for medical diagnoses. They can be found, for example, in doctor's letters or on certificates of incapacity for work. E78

Hypercholesterolemia: description

Hypercholesterolemia is a disorder of fat metabolism in the body. This increases the amount of cholesterol in the blood. Cholesterol (cholesterol) is an essential natural substance in animal cells. It is extremely important for the structure of the cell membrane. In addition, cholesterol is required for the production of bile acids for fat digestion in the intestine and for the synthesis of sex hormones (testosterone, estradiol, progesterone). The stress hormone cortisol and the messenger substance aldosterone (water and salt balance) are also formed from cholesterol.

Only a small part of the cholesterol is ingested with food. A far larger proportion is produced by the body itself, mainly in the liver and the intestinal mucosa. This process is called cholesterol biosynthesis. This produces 7-dehydrocholesterol as an intermediate. This substance is the precursor to the vital vitamin D.

Usually the total cholesterol level in the blood is less than 200 milligrams of cholesterol per deciliter. Doctors consider slightly elevated cholesterol levels (200-239 mg / dl) to be borderline. If the values ​​continue to rise, the cholesterol level is too high, i.e. hypercholesterolemia.

Lipoproteins

Cholesterol is only about 30 percent free in the human body. The remaining 70 percent are associated with fatty acids (cholesterol esters). As a fat-like substance, cholesterol is insoluble in water. In order to be able to be transported in the blood, however, it has to become water-soluble. To do this, cholesterol and cholesterol esters combine with other substances. Together with lipids (fats: triglycerides, phospholipids) and proteins (apoproteins) it forms fat-protein complexes, so-called lipoproteins.

Depending on the composition, a distinction is made between different lipoproteins. The most important are chylomicrons, VLDL (very low density lipoproteins), LDL (low density lipoproteins) and HDL (high density lipoproteins). There is also IDL (intermediate density lipoproteins), which stands between LDL and VLDL, and lipoprotein a, which is similar in structure to LDL.

Chylomicrons transport dietary fats (triglyceride content 85 percent) from the intestine into the body. VLDL, in turn, consists mainly of triglycerides, which are formed in the liver. This lipoprotein is eventually converted into IDL and LDL. In the process, it loses its fats, whereas the cholesterol level increases.

The lipoproteins LDL and HDL play a crucial role in hypercholesterolemia. They consist largely of cholesterol and keep the cholesterol level in balance. LDL transports cholesterol from the liver via the blood to the rest of the body's cells. Increased LDL also means increased cholesterol values ​​up to hypercholesterolemia. As a result, the cholesterol is deposited in the blood vessels and thus leads to arteriosclerosis (plaques, "vascular calcification"). The lipoprotein HDL counteracts this. It transports excess cholesterol back to the liver, thus preventing high cholesterol levels.

This is why LDL is also known as "bad" and HDL as "good cholesterol".

Hypercholesterolemia as a group of disorders of lipid metabolism

Hypercholesterolemia is the result of a disorder in lipid metabolism and is associated with increased cholesterol levels. Lipid metabolism disorders are also known as hyperlipoproteinemia, hyperlipidemia or dyslipidemia. In addition to hypercholesterolemia, it also includes hypertriglyceridemia. In addition, there is a combined hyperlipidemia. Those affected have high cholesterol and high triglyceride fats in their blood.

Hypercholesterolemia: symptoms

Hypercholesterolemia, i.e. increased cholesterol levels in the blood, does not itself cause any symptoms. Rather, the hypercholesterolemia is a sign of other diseases. In the long run, however, high blood cholesterol can have serious consequences.

arteriosclerosis

LDL is responsible for the distribution of cholesterol in the body, which is typically increased in hypercholesterolemia. If the HDL lipoproteins are reduced, the transport of cholesterol back to the liver is also disturbed. The result is hypercholesterolemia. The excess cholesterol is deposited in the vessel walls. A process is then set in motion that ultimately damages the vessels (arteries = arteries). Because with the cholesterol, fats, carbohydrates, blood components, fiber tissue and calcium accumulate in the vessel wall. Hypercholesterolemia thus leads to arteriosclerosis, popularly known as vascular calcification.

CHD and heart attack

With calcification of the vessels, the arteries become increasingly narrowed. If the heart vessels are affected, doctors speak of coronary heart disease (CHD). In this way, hypercholesterolemia can also lead to heart attack. The risk of heart attack is roughly doubled with a total cholesterol level (HDL plus LDL) of 250 mg / dl. With a total value of over 300 mg / dl, it is four times as high as in people with normal cholesterol levels. The coronary arteries are in some cases almost completely closed and the heart muscle can no longer be properly supplied with oxygen. Sufferers complain of a feeling of pressure or pain in the chest. Palpitations, dizziness, sweating and shortness of breath are also signs of a heart attack.

PAOD and stroke

If the arteries of the legs are damaged by hypercholesterolemia, intermittent claudication can develop. Doctors speak of PAOD (peripheral arterial occlusive disease). The patients suffer from painful circulatory disorders, especially under stress (e.g. when going for a walk). If the cervical and cerebral arteries are narrowed due to hypercholesterolemia, this can lead to a lack of oxygen in the brain. There is a risk of short-term (TIA = transitory ischemic attack) neurological failures such as paralysis on one side or even a stroke (ischemic cerebral infarction).

Xanthomas

Xathome are fat deposits in tissue, primarily in the skin.As a result of hypercholesterolemia, but also hypertriglyceridemia, fats and cholesterol accumulate on the trunk or hands, for example, and form yellow-orange skin thickenings (flat xanthomas). If high cholesterol is deposited in the eyelids, doctors speak of xanthelasma.

Larger skin thickenings of a yellow-brownish color on the elbows or knees are called tuberous xanthomas. Xanthomas on the finger or Achilles tendons are also symptoms of hypercholesterolemia. Yellowish lumps on reddened skin, especially on the buttocks and the extensor sides of the arms and legs, are typical of hypertriglyceridemia. Medically, these skin conditions are called eruptive xanthomas. Fat deposits on the hand lines usually speak for an increase in IDL and VLDL.

Hypercholesterolemia of the eye

Cholesterol that is too high can also build up in the cornea of ​​the eyes. There a visible clouding ring of gray-white color forms on the edge of the cornea. Doctors speak of an arcus (lipoides) corneae in this case. This lipid ring is common in the elderly and is considered harmless. In adults under 45 years of age, however, it is a clear indicator of hypercholesterolemia.

Hypercholesterolemia: causes and risk factors

Hypercholesterolemia is more of a symptom than a mere clinical picture. This also applies to other hyperlipidemias. Mostly they are the result of another illness or a certain lifestyle. Depending on the cause of hypercholesterolemia, three groups are distinguished.

Reactive-physiological form

A diet high in cholesterol falls into this group, for example. In response to this, the fat metabolism in the human body is overloaded. Cholesterol that is ingested too much cannot be excreted quickly enough and causes high blood cholesterol levels. Alcohol can also lead to hypercholesterolemia, especially when there is increased IDL in the blood. In the reactive-physiological form, however, increased cholesterol levels can only be detected temporarily. After a short time, the values ​​normalize again.

Secondary form

In the secondary form of hypercholesterolemia, other diseases cause high cholesterol levels. These include, for example, the diabetes mellitus. LDL is normally absorbed by certain receptor structures (LDL receptors) in the body's cells. This lowers the high cholesterol level in the blood. It is precisely this LDL uptake that is delayed in type 1 diabetes, as the messenger substance insulin is missing here. The cholesterol therefore remains in the blood and the patient develops hypercholesterolemia. In obesity, the formation of LDL cholesterol is increased. In addition, insulin no longer works properly (insulin resistance, type 2 diabetes). Fatty acids increasingly reach the liver, which increases VLDL (hypertriglyceridemia).

thyroid

An underactive thyroid (hypothyroidism) can also lead to hypercholesterolemia. In hypothyroidism, the thyroid's messenger substances are reduced. However, they significantly influence the metabolic processes in the body. With low thyroid hormones, for example, fewer LDL receptors are formed, which ultimately leads to an increased cholesterol level.

Nephrotic Syndrome and Cholestasis

Nephrotic syndrome arises due to damage to the kidneys. Typically, there are increased protein levels in the urine (proteinuria), decreased protein levels in the blood (hypoproteinemia, hypoalbuminemia) and water retention in the tissue (edema). But hypercholesterolemia and triglyceridemia are also classic signs of nephrotic syndrome. The "good" HDL cholesterol is often reduced. Furthermore, a build-up of bile in the bile ducts (cholestasis) leads to increased lipoprotein values ​​and thus to hypercholesterolemia.

Medication

Numerous drugs can also adversely affect lipid metabolism. Most cortisone preparations lead to hypercholesterolemia. Treatments with estrogens, the pill, water tablets (thiazides) or beta blockers usually increase the triglycerides in the blood. In addition, high cholesterol levels have been observed in pregnant women. In this case, however, the hypercholesterolemia has hardly any disease value.

Primary form

This is also referred to as familial or hereditary (hereditary) hypercholesterolemia. The cause of high cholesterol levels is a defect in the genetic make-up. Experts differentiate polygenetic from monogenic hypercholesterolemia. In polygenetic hypercholesterolemia, several errors in the building blocks of the human genome (genes) lead to slightly increased cholesterol levels. External factors such as poor nutrition and lack of exercise are usually added.

Familial monogenetic hypercholesterolemia

In monogenic hypercholesterolemia, the fault lies solely in the gene that contains the information for the production of LDL receptors. They are used to clear the LDL cholesterol from the blood. In monogenetic familial hypercholesterolemia, these receptors are either absent or their function is either completely absent (homozygous carriers) or the receptors are less active (heterozygous carriers). Affected persons without a healthy gene (homozygous) already have the first symptoms in childhood or adolescence. Heterozygotes have both diseased and healthy genes and usually suffer first heart attacks in middle age unless their hypercholesterolemia is treated. Familial hypercholesterolemia can be inherited (autosomal dominant inheritance).

Hypercholesterolemia due to various apolipoproteins

Another genetic defect can affect the apolipoprotein B100. This protein is involved in building up LDL and helps the cells to absorb LDL cholesterol. More specifically, it works by binding LDL to its receptor. If the function of the apolipoprotein B100 is disturbed, more cholesterol remains in the blood. This hypercholesterolemia can also be inherited (autosomal dominant). In addition to apolipoprotein B100, there are also various forms of apolipoprotein E. Medicine has established that hypercholesterolemia occurs mainly in people with the apolipoproteins E 3/4 and E 4/4. You are also at increased risk of developing Alzheimer's.

Hypercholesterolemia due to PCSK9

PCSK9 (Proproteinkonvertase Subtilisin / Kexin Type 9) is an endogenous protein (enzyme) that occurs primarily in the liver cells. This enzyme binds LDL receptors, whereupon they are broken down. As a result, the liver cells can "fish" less cholesterol from the blood. Hypercholesterolemia occurs. Studies have shown that certain defects in the genetic material (mutations) of the enzyme increase its effect (gain-of-function). As a result, high cholesterol levels continue to rise. However, cases have also been described in which PCSK9 has lost its function due to mutations (loss-of-function), as a result of which the risk of hypercholesterolemia is reduced.

Other hereditary dyslipidemias

Other lipid metabolism disorders can also be based on genetic defects. Here too, those affected usually have high cholesterol levels in their blood:

illness	disturbance	Disease characteristics
Familial combined hyperlipoproteinemia	Overproduction and disruption of VLDL degradation inherited as an autosomal dominant trait	Hypercholesterolemia Hypertriglyceridemia increased CHD risk
Familial hypertriglyceridemia	inherited as an autosomal dominant trait	Hypertriglyceridemia decreased HDL level increased risk of inflammation of the pancreas (pancreatitis) CHD risk only increased with very low HDL values
Familial dysbetalipoproteinemia	several disorders, especially in the IDL / VLDL metabolism Apolipoprotein E 2	rather seldom Hypercholesterolemia (in very high cholesterol VLDL) Hypertriglyceridemia very high risk of CHD, PAOD and stroke Palm line xanthomas and tubero-eruptive xanthomas typical
Hyperchylomicronemia	with pronounced hypertriglyceridemia Defect of the enzyme lipoprotein lipase or Deficiency of apolipoprotein CII	Hypertriglyceridemia increased risk of pancreatitis eruptive xanthomas and liver enlargement possible in childhood
Familial hypoalpha-lipoproteinemia	= Tangier disease impaired cholesterol release	low HDL levels (also low in total cholesterol) increased CHD risk Nerve damage possible Enlarged tonsils with yellow-orange spots are typical in childhood

In addition, the lipoprotein a can be increased. It is made up of LDL and apolipoprotein a. Among other things, it inhibits blood coagulation processes, especially when dissolving blood clots (plasminogen competitor). This accelerates the calcification of the vessels (blood clots are involved in the formation of plaque in the vessel walls). In the case of LDL hypercholesterolemia, the lipoprotein a also increases the risk of cardiovascular diseases.

Hypercholesterolemia: diagnosis and examination

Hypercholesterolemia is determined by a blood test. In many cases, the elevated cholesterol levels are accidentally noticed. You can have your cholesterol level determined by your family doctor or a specialist in internal medicine (internist). To do this, he takes blood samples. This blood sample should be taken on an empty stomach, ideally after a twelve-hour fast (especially important for triglycerides). The blood is then examined in the laboratory for triglycerides, LDL and HDL as well as total cholesterol and possibly also for lipoprotein a. If the values ​​are increased, blood is drawn again, this time after eating. The following guide values ​​apply to healthy adults without risk factors for vascular calcification:

LDL cholesterol	<160 mg / dl
HDL cholesterol	> 35-40 mg / dl
Total cholesterol	under 19 years of age <170 mg / dl 20-29 years <200 mg / dl 30.-40. Lj. <220 mg / dl over 40 years of age <240 mg / dl
Triglycerides	<150-200 mg / dl
Lipoprotein a (Lp a)	<30 mg / dl

If hypercholesterolemia was found when the blood sample was taken, the doctor will check the values ​​after about four weeks. He can also use the LDL and HDL cholesterol levels to determine the "arteriosclerosis risk index". To do this, the LDL value is divided by the HDL value (LDL / HDL quotient). A result below two means a low risk, values ​​above four a high risk of vascular damage.

Since hypercholesterolemia is a symptom, doctors need to make a more accurate diagnosis. For this purpose, the German Society for Fat Science has published a scheme with the help of which hypercholesterolemia can be assigned to a disease.

LDL cholesterol blood count	Family history for coronary artery disease (CHD)	diagnosis
> 220 mg / dl	positive	Familial hypercholesterolemia
	negative	Polygenic hypercholesterolemia
190-220 mg / dl	positive	Familial combined hyperlipidemia (especially with elevated triglycerides)
	negative	Polygenic hypercholesterolemia
160-190 mg / dl	positive	Familial combined hyperlipidemia (especially with elevated triglycerides)
	negative	Purely nutritional hypercholesterolemia

Medical history (anamnesis)

Taking a medical history (anamnesis) is of crucial importance in the case of hypercholesterolemia. It provides the doctor with information on possible causes and risk factors. The doctor will ask you about your eating habits and your alcohol or cigarette consumption. Also tell the doctor any known illnesses you suffer from, such as diabetes, thyroid or liver disease. Among other things, the doctor could ask the following questions:

• Do you smoke? How much alcohol do you drink roughly?
• Do you already suffer from illnesses? If so, under which ones?
• Do you take medication permanently and what are their names?
• Do you sometimes feel pain in your legs when you go for a walk, sometimes so bad that you have to stop?
• Has hypercholesterolemia been diagnosed in your family?

Physical examination

After the detailed questioning, your doctor will examine you physically. Risk factors such as being very overweight can be identified at first glance. It is also important how the fat is distributed. Abdominal fat in particular is considered to be of concern in connection with hypercholesterolemia. The doctor may calculate your BMI (body mass index) from your weight and height. The doctor also measures blood pressure and pulse and listens to heart and lungs (auscultation). In addition, water (edema) and fat deposits in the skin or on the muscle tendons (xanthomas) can indicate hypercholesterolemia. Fat deposits in the eye (opacity ring, arcus corneae) also indicate a disturbed lipid metabolism.

Risk calculation

As part of the examinations of the body and blood, the doctor can determine a risk value for cardiovascular diseases. The value indicates how high the risk is that the respective patient will suffer a heart attack in the next ten years. There are various calculation systems for this. The PROCAM and CARRISMA risk calculators, the Framingham score, especially in the USA, and the ESC score for fatal events are widespread. All of them take into account increased cholesterol levels, among other things.

Further research

Your doctor may do further tests. If there are signs of diseases that cause hypercholesterolemia, these must be investigated. With the help of an ultrasound (sonography), the doctor can also visualize the condition of large arteries - for example the carotid arteries - and assess the degree of vascular calcification. The blood flow in the arteries can also be audibly checked using the so-called Doppler probe (duplex sonography). If hereditary hypercholesterolemia is suspected, genetic and family tests can confirm the diagnosis.

Hypercholesterolemia: treatment

The primary goal of hypercholesterolemia therapy is to lower the risk of dangerous vascular calcifications and thus of cardiovascular diseases. Treatment should keep LDL and HDL cholesterol and triglycerides in a specific target range. The triglycerides are lowered below 150 mg / dl in all cases. The HDL cholesterol is ideally over 40 mg / dl in men and over 50 mg / dl in women. When lowering LDL hypercholesterolemia, the target value is influenced by any risk factors or existing diseases. The risk factors include:

• High blood pressure (arterial hypertension)
• smoking
• Heart disease in close relatives (CHD / myocardial infarction in first-degree relatives; in men before the age of 60, in women before the age of 70)
• Age (men over 45 years, women over 55 years)
• HDL cholesterol <40 mg / dl

There are currently different guide values. For primary hypercholesterolemia, according to the recommendations of the German Society for Combating Lipid Metabolism Disorders and their Consequences (Lipid-Liga, 2011), a target value below 160 mg / dl is aimed for with fewer than two of these risk factors.

If a patient with hypercholesterolemia has two or more risk factors, the LDL cholesterol should be below 130 mg / dL. If an affected person suffers from a vascular disease (e.g. heart attack, CHD, PAD) or from diabetes, the hypercholesterolemia is reduced to below 100 mg / dl. The same applies if the calculated 10-year risk (e.g. PROCAM) is over 20 percent. If a patient has both vascular disease and diabetes, the LDL cholesterol value should be less than 70 mg / dl.

Hypercholesterolemia therapy goals of the German Society for Cardiology

Here the experts follow the recommendations of the European Cardiologist Association ESC. This has developed a SCORE model in which gender, age, smoking status, systolic (upper) blood pressure value and overall increased cholesterol values ​​are taken into account. The resulting ESC score records the risk of a fatal cardiovascular event within the following ten years. In addition, the patients are divided into four groups:

risk	Condition (if one applies, the patient is already assigned to this risk group)
low	10-year risk under one percent according to the SCORE model
moderately increased	10-year risk according to the SCORE model greater than or equal to one percent but less than five percent Consideration of additional risk factors: social disadvantage, severe obesity, low HDL cholesterol, impaired vascular walls (e.g. plaques in the carotid arteries), increased blood values ​​for fibrinogen, triglycerides, homocysteine ​​and others
high	Significant increase in the main risk factors (e.g. high blood pressure), presence of familial hypercholesterolemia (dyslipidemia) 10-year risk according to the SCORE model greater than or equal to five percent but less than ten percent
very high	Diagnosed cardiovascular disease, (previous) myocardial infarction, stroke, PAD, measures to restore blood flow to blood vessels (especially the coronary arteries) Type 2 diabetes Type 1 diabetes with organ damage Chronic kidney disease (GFR less than 60 ml / min / 1.73 m2) 10-year risk according to the SCORE model over ten percent

Low risk patients should make lifestyle changes if their cholesterol levels are above 100 mg / dL. Drug treatment is only considered if the LDL hypercholesterolemia remains above 190 mg / dl for a longer period of time.If the risk is moderately increased, the experts recommend that increased cholesterol levels are lowered to below 115 mg / dl by improving lifestyle and eating habits and, if necessary, using medication.

High-risk hypercholesterolemia should be reduced to below 100 mg / dL with medication. And patients at very high risk should have LDL levels below 70 mg / dL. If this treatment goal is not achieved, the experts recommend lowering high cholesterol by at least half of the initial value.

Strictly speaking, these guidelines do not deal with the treatment of actual hypercholesterolemia. If the cholesterol level in low-risk patients is between 70 and 100 mg / dl, for example, no treatment is necessary. If the risk is very high, however, medication is used immediately in this area to prevent further cardiovascular diseases.

Hypercholesterolemia is therefore not simply defined by increased cholesterol levels above 200 mg / dl. Rather, depending on the type and number of existing risk factors, it is a matter of a different high cholesterol value for the respective person concerned.

That is why some experts do not speak of a hypercholesterolemia treatment, but of a lipid- or cholesterol-lowering therapy. This prevents cardiovascular diseases at an increased risk - especially if there is hypercholesterolemia - (secondary prevention) and is intended, for example, to prevent further life-threatening illnesses after a heart attack (tertiary prevention).

Levels of hypercholesterolemia treatment

First and foremost is the change in lifestyle and eating habits. Obese patients should try to reach a normal body weight. People of normal weight should maintain their weight. Many patients always ask themselves the question "Cholesterol too high, what to do?". The following tips can help you combat or avoid hypercholesterolemia.

Do sport or be consciously active in your everyday life!

For example, climb stairs instead of using the elevator! Take your bike to work instead of the car! This not only counteracts LDL hypercholesterolemia, but also lowers your triglyceride levels. In addition, the "good" HDL increases. In addition, this is the most effective way to lose weight and prevent further cardiovascular diseases or diabetes!

Avoid excessive use of butter!

Many sufferers already find it helpful to replace butter with diet margarine and vegetable oils. In general, a high level of unsaturated fatty acids is beneficial, whereas saturated fatty acids should be avoided. Some experts assume that the high cholesterol level can be reduced by about eleven percent in this way. Products with phytosterols (e.g. sitostanol) are recommended. They inhibit the absorption of cholesterol and should also be able to limit its production in the body. A daily intake of around one to three grams is recommended for children and adolescents with hypercholesterolemia. Too much phytosterols, however, have the opposite effect. They are very similar to cholesterol and can in turn cause vascular calcification.

Watch out for and avoid hidden fat!

This is mainly found in milk and dairy products (cheese!), Sausage, sauces and ready meals. Fast food is also usually high in fat. Instead, use reduced-fat products to counteract hypercholesterolemia. Also choose lean meats and sausages that are low in saturated fat. These include, for example, low-fat fish such as trout or cod, game, veal and poultry.

Prepare your meals with low fat content! Eat fruits and vegetables every day!

Cook without edible fat! Grilling and stewing are suitable methods of preparation to reduce or prevent hypercholesterolemia. Experts also recommend consuming fruits and vegetables as raw vegetables (e.g. in a salad).

Cut Down on High Cholesterol Foods!

These include, in particular, egg yolks (and their further processing such as mayonnaise), offal or shellfish and crustaceans.

Pay attention to protein and fiber!

Vegetable protein in particular, which is particularly found in soy products, can lower hypercholesterolemia. Because this increases the absorption of LDL and lowers the high cholesterol level. Fiber, on the other hand, keeps you full for a long time and thus often prevents overeating. Oat bran, pectin, guar and psyllium are even said to have a direct effect on hypercholesterolemia. However, a lot of fiber can also weaken or cancel out the effects of cholesterol-lowering drugs.

Quit smoking and drink alcohol only in moderation!

In the case of severe hypertriglyceridemia, doctors even recommend completely avoiding alcohol. This can also help prevent other health problems such as liver damage. In addition, if you have hypercholesterolemia with increased triglycerides, you should avoid soft drinks containing sugar.

Prefer "complex" carbohydrates!

Carbohydrates are made up of sugar molecules that are strung together like pearls in a chain. Short chains are absorbed quickly and are more likely to be harmful to the sugar balance in the body. They are in particularly sweet dishes (e.g. sweets). However, carbohydrates are an important source of energy. Therefore, eat long-chain, complex carbohydrates like whole grains.

Stay balanced!

Diets that are too hard are more likely to harm the body than to benefit it! Therefore, when making a change, it is important to train yourself to other eating habits in the long term and not to abruptly give up everything. Frequent unsuccessful diet attempts actually increase the risk of cardiovascular disease. This is why nutritionists prefer to speak of a fat-modified diet: You only have to change part of your eating habits and concentrate on vegetable instead of animal fats.

Food composition

The German Society for Combating Lipid Metabolism Disorders and their Consequences (Lipid League) advocates the following recommendation as to how the daily diet should be composed:

nutrient	Amount or proportion of total energy input per day	suitable food samples
carbohydrates	50-60 percent	Fruit, potatoes, vegetables, cereal products
protein	10-20 percent	Fish, lean poultry, reduced-fat milk (products)
Fiber	more than 30 grams / day	Vegetables, fruit, whole grain products, oat bran (cereals)
fat	25-35 percent	Butter, frying fat, fatty meat and dairy products Beware of hidden fat!
Fatty acids	saturated 7-10 percent	animal fat
	monounsaturated 10-15 percent polyunsaturated 7-10 percent	Canola, olive, soy, corn germ, sunflower oil, diet margarine
cholesterol	less than 200-300 grams / day	Egg yolks (no more than two per week), egg yolk products (e.g. egg noodles, mayonnaise), offal

Treatment of other diseases

There are a number of diseases that can lead to hypercholesterolemia. Therefore, your doctor will treat these diseases as well. If you suffer from diabetes or an underactive thyroid, you should definitely follow your doctor's suggestions for therapy. Also take your medication consistently in order to be able to successfully counteract hypercholesterolemia. If you have any doubts or questions, do not hesitate to ask your doctor for advice.

Drug treatment for hypercholesterolemia

If the hypercholesterolemia has not been sufficiently reduced through a change in lifestyle and diet, the doctor will prescribe medication for the increased cholesterol level. Children with hypercholesterolemia usually do not receive drug treatment until they are seven to eight years old. At the beginning of drug treatment for hypercholesterolemia, the doctor usually only prescribes one preparation, usually statins. If the high cholesterol levels are not lowered enough, he increases the dose. If there is no significant improvement after three to six months, he extends the therapy with other hypercholesterolemia drugs.

Statins (CSE inhibitors)

Statins inhibit a protein called HMG-CoA reductase. The liver cells need this enzyme in order to be able to produce the body's own cholesterol. If the enzyme is inhibited, the cholesterol level in the cells drops (cholesterol synthesis enzyme inhibitor = CSE inhibitor). As a result, more LDL receptors are built into the cell envelope. The cell can absorb cholesterol from the blood through these "tentacles". The hypercholesterolemia decreases.

Anion exchange resins - bile acid binders

Bile acids are produced in the liver. They make up the bile that is released into the small intestine for digestion. The cholesterol-containing bile acids are later reabsorbed and return to the liver via the blood, where they become bile again (enterohepatic circulation). Anion exchange resins or bile acid binders bind these bile acids in the intestine. As a result, they disappear from the enterohepatic circulation with their cholesterol. In order to obtain new cholesterol for the bile, the liver cells stimulate their LDL receptors. Cholesterol is absorbed from the blood and hypercholesterolemia improves. Well-known active ingredients are colestyramine and colesevelam. Both are often combined with statins to adequately treat hypercholesterolemia.

Cholesterol absorption inhibitors

The active ingredient is called ezetimibe and it prevents the uptake (absorption) of cholesterol from the intestines. For the treatment of hypercholesterolemia there is a fixed combination with the CSE inhibitor simvastatin.

Fibrates

In addition to hypercholesterolemia therapy, fibrates are mainly used to treat increased triglyceride and decreased HDL levels. The effect is complex. Among other things, the breakdown of triglyceride-rich lipoproteins increases. With regard to hypercholesterolemia, however, one thing must be considered: In combination with statins, the risk of muscle damage increases (myopathy; rarely also rhabdomyolysis with dissolution of the muscle fibers).

Nicotinic acid

This medicine is also combined with statins to treat hypercholesterolaemia. In a 2011 study in the USA with the nicotinic acid preparation Niaspan in combination with statins, however, a benefit could not be confirmed. The risk of cardiovascular disease did not decrease compared to hypercholesterolemia patients who took CSE inhibitors only. Rather, there were even more strokes, which is why Niaspan was withdrawn from the market. The successor Tredaptive is also no longer available.

Omega-3 fatty acids

Omega-3 fatty acids are said to have numerous benefits. The European Food Safety Authority EFSA published a report in 2010 on the alleged effects of various omega-3 fatty acids, as there are many partly contradicting studies in this regard. According to the experts, the intake of omega-3 fatty acids supports normal heart function. However, the experts denied the positive effect on hypercholesterolemia. Also beneficial effects on the immune system or the blood sugar balance have not been confirmed. However, since omega-3 fatty acids have very few side effects, they are recommended by some doctors to reduce hypertriglyceridemia. They can also be easily combined with other fat-reducing substances.

PCSK9 inhibitors

After much research, PCSK9 inhibitors were finally approved in Europe for the treatment of high cholesterol levels in autumn 2015. The active ingredients in this group of drugs are proteins, or more precisely antibodies that bind to PCSK9 enzymes and thus render them ineffective. As a result, more LDL receptors are available again, which counteract hypercholesterolemia.

PCSK9 inhibitors are mainly used in combination with statins for severe (familial) hypercholesterolemia, especially if previous therapies have only insufficiently lowered a high cholesterol level. The doctor can also prescribe this active ingredient if the patient cannot tolerate statins. PCSK9 antibodies are usually administered under the skin (subcutaneously) every two to four weeks using a syringe. However, due to the high treatment costs, the use of PCSK9 inhibitors is rather cautious.

LDL apheresis

In some cases, hypercholesterolemia cannot be adequately reduced even with several medications. This is the case, for example, in severe familial hypercholesterolemia. If there is also vascular damage, the blood is "washed" outside the body and the excessively high cholesterol is removed. In an artificial circuit, the blood is piped to a machine. There it is either split up into plasma and cells or directly cleaned of LDL. The now "clean" blood is then returned to the body via tubes. LDL apheresis can also be used to lower elevated lipoprotein a, IDL and VLDL levels. The procedure is usually done once a week. At the same time, the hypercholesterolemia continues to be treated with medication.

Hypercholesterolemia: disease course and prognosis

The course of hypercholesterolemia can be very different. Depending on the cause, the extent of the increased cholesterol level differs. For example, people with hereditary hypercholesterolemia have a significantly higher risk of dying from a heart attack. Studies show that affected men and women often had a blood clot in the coronary arteries before the age of 60 than people with normal cholesterol levels.

Many different factors also play a role in the risk of vascular calcification and the following cardiovascular diseases. Therefore, make sure you have a healthy lifestyle. Also, follow your doctor's advice and have regular checkups. The individual forms of therapy respond differently to each patient. Ultimately, through your personal commitment, you can achieve the success of the treatment and prevent the dangerous secondary diseases of hypercholesterolemia.

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