Hypercholesterolemia

What is hypercholesterolemia?

It is the increase in cholesterol (fat) levels in the blood. There are two types of fat present in the blood that are of medical interest: cholesterol and triglycerides.

Both are involved in the development of heart problems, with cholesterol being the more significant factor. In the case of cholesterol, there are two main types: high-density lipoprotein (HDL) and low-density lipoprotein (LDL).

HDL, also known as “good cholesterol,” plays a protective role by helping to remove fatty plaques from inside blood vessels. Therefore, the higher the HDL levels, the better for the individual.

LDL, on the other hand, contributes to the formation of atheromatous plaques—fat deposits that clog the walls of blood vessels—and is closely linked to the development of conditions such as myocardial infarction (“heart attack”) and cerebrovascular accident (“stroke”).

Causes

In some cases, hypercholesterolemia is caused by other conditions (secondary hypercholesterolemia), such as hypothyroidism, or even by the use of certain medications. However, most cases are due to primary hypercholesterolemia, which involves both environmental and hereditary factors.

Symptoms

Hypercholesterolemia is usually an asymptomatic condition, only causing symptoms after many years, when elevated LDL cholesterol in the blood leads to the buildup of fatty plaques (atheromas) in the body’s blood vessels—a process known as atherosclerosis.

Atherosclerosis begins microscopically during adolescence, but its manifestations are more commonly seen after the age of 40. It tends to affect three main areas: the carotid arteries, which supply blood to the brain; the arteries that carry blood to the legs (iliac and femoral vessels); and the coronary arteries, which supply blood to the heart muscle (myocardium).

In the first case, the direct consequence is a stroke. In the second, symptoms such as leg pain while walking, loss of sensation in the feet, or even amputation due to gangrene may occur.

In the third case, symptoms include angina (chest pain) or myocardial infarction (heart attack). It is important to note that, in addition to being silent, atherosclerosis is insidious, as one-quarter of cases present as sudden death (commonly known as a “massive heart attack”).

Diagnosis

Diagnosis is made by measuring cholesterol levels in the blood.

The test is performed after fasting for at least 10 hours and includes the three components mentioned previously. Every individual should have their blood cholesterol and triglyceride levels checked starting at age 9, and in selected cases—especially when there is a strong family history—even earlier.

This allows for early treatment, at a stage when the devastating damage to blood vessels has not yet occurred, making it possible to prevent serious health problems.

Treatment

Treatment primarily involves behavioral measures and medication. In the first case, diet and physical activity are essential.

Individuals with hypercholesterolemia should restrict saturated fats, which are fats of animal origin, as these are directly responsible for increasing LDL levels in the body.

Additionally, they should avoid foods rich in trans fats—vegetable fats that have been chemically modified and are commonly used to enhance flavor and color in processed foods such as snacks, chips, cookies, and fried items.

Preference should be given to fats of plant origin, such as canola and sunflower oils, olive oil, and nuts (such as cashews, almonds, walnuts, and peanuts), as these help increase HDL levels.

There is some controversy regarding egg consumption, but it is now known that eating eggs in moderation (up to one per day) has little impact on blood LDL levels. Individuals with high triglyceride levels should limit sugars, pasta, and alcoholic beverages.

In selected cases—especially in individuals with very high blood cholesterol levels (LDL above 190 mg/dL), diabetics, and those with established cardiovascular disease (e.g., history of heart attack, stroke, coronary bypass surgery, etc.)—medications are necessary.

The most well-known drugs are statins, which significantly reduce LDL levels. Other options include fibrates, ezetimibe, nicotinic acid, and omega-3.

Soon, new injectable medications will become available in Brazil, capable of dramatically reducing LDL levels (more than twice the reduction achieved with statins), particularly for cases of familial hypercholesterolemia—a hereditary condition in which LDL cholesterol levels are extremely high and pose a risk of heart problems even in young individuals.

Prevention

The best form of prevention is diet, as previously mentioned, especially for those with a strong family history (e.g., first-degree relatives with the condition). Even so, it is known that only about 10% of blood cholesterol comes from diet, meaning that the use of medication becomes necessary at some point.

Incidence in Brazil

The number of people with hypercholesterolemia is difficult to determine, especially considering changes in severity criteria and the thresholds at which treatment begins. The familial form, however, is estimated to affect around 300,000 Brazilians.

By Einstein Editorial Board