High Cholesterol: What You Need to Know About Hypercholesterolemia

High cholesterol isn’t something you feel. No pain, no warning signs, no sudden dizziness. That’s why it kills so quietly. By the time you notice something’s wrong-chest pain, a stroke, a heart attack-the damage has been building for years. This is hypercholesterolemia: abnormally high levels of cholesterol in your blood. It’s not just a number on a lab report. It’s a silent timer ticking toward heart disease, the number one cause of death worldwide.

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 there’s too much-especially the kind called LDL, or "bad" cholesterol-it starts sticking to your artery walls. Over time, that builds up into plaque. Narrowing your arteries. Blocking blood flow. That’s how heart attacks and strokes happen.

The numbers matter. The American Heart Association says total cholesterol above 200 mg/dL is considered high. But the real red flag is LDL. If your LDL is over 190 mg/dL, you’re in the severe range. For most people, doctors aim to get it below 100 mg/dL. If you’ve already had a heart attack or have diabetes, they’ll push for even lower-under 70 mg/dL.

Two Types: Genetics vs. Lifestyle

Not all high cholesterol is the same. There are two main types, and knowing which one you have changes everything.

Familial hypercholesterolemia (FH) is genetic. You’re born with it. It’s caused by a faulty gene-usually in the LDLR or PCSK9 gene-that stops your body from cleaning LDL out of your blood. One in every 250 people has this. That’s more than you think. People with FH often have LDL levels above 190 mg/dL from childhood. Some even have levels over 450 mg/dL. And they don’t need to eat junk food to get there. Their bodies just can’t handle cholesterol the way yours does.

Physical signs can give it away. Yellowish bumps around the eyelids (xanthelasmas), thickened tendons in the heels or knuckles (tendon xanthomas), or a gray ring around the cornea of the eye. These aren’t rare in FH. They’re clues. If you have them before age 40, get tested. Left untreated, men with FH can have a heart attack before 40. Women before 50.

Acquired hypercholesterolemia is the other kind. This is the one tied to what you eat, how much you move, and other health conditions. Think obesity, type 2 diabetes, hypothyroidism, or chronic kidney disease. Some medications like certain diuretics or steroids can also raise it. This type usually shows up later in life. LDL levels might be 160-189 mg/dL-not as extreme as FH, but still dangerous if ignored.

Why You Can’t Just "Eat Better" If You Have FH

Here’s the myth: "Just cut out eggs and butter, and your cholesterol will drop." It works for some people. But if you have familial hypercholesterolemia, diet alone won’t cut it. Your body is broken in a way that no amount of kale or oatmeal can fix.

Studies show that lifestyle changes like the Portfolio Diet (which includes nuts, plant sterols, soluble fiber, and soy) can lower LDL by 10-15% in people with diet-related high cholesterol. But for FH patients? That same diet might only drop LDL by 5%. Not enough. That’s why doctors don’t wait. They start medication right away.

Statins are the first line. Drugs like atorvastatin or rosuvastatin can slash LDL by 50% or more. But many FH patients need more. Ezetimibe adds another 15-20% drop. Then there are PCSK9 inhibitors-injectables like alirocumab or evolocumab-that can knock out another 50-60%. Some people end up on all three at once. It sounds intense, but for FH, it’s survival.

How It’s Diagnosed (And Why Most People Miss It)

You don’t feel high cholesterol. That’s the problem. There’s no symptom until it’s too late. The only way to know is a simple blood test-a lipid panel. The good news? You don’t even have to fast anymore. Most labs accept non-fasting tests now, making it easier to get checked.

Guidelines recommend everyone between 40 and 75 get screened during their regular checkups. But here’s the gap: only about half of people at risk actually get tested. And even fewer get treated properly. In the U.S., only 55% of eligible adults are on statins. Among Black adults, it’s 42%. Women? Just under 50%. Why? Fear of side effects. Misunderstanding. Lack of access. Or just not knowing they’re at risk.

If you have a family history of early heart disease-before age 55 for men, 65 for women-that’s a red flag. Get tested, even if you’re young. If your dad had a heart attack at 48, your cholesterol might be high too. Don’t wait for symptoms.

What Happens If You Do Nothing

Untreated heterozygous FH? Life expectancy drops by about 30 years. The average age for a first heart event? 53 for men, 60 for women. That’s not old. That’s middle age. And it’s preventable.

Every 39 mg/dL reduction in LDL cuts your risk of a major heart event by 22%. That’s not a guess. It’s from a major study published in the Journal of the American College of Cardiology. Lower LDL = fewer heart attacks. It’s that direct.

But it’s not just about the heart. Plaque buildup affects your brain too. High cholesterol is a leading cause of stroke. It also increases your risk of peripheral artery disease-pain in your legs when you walk because your arteries are clogged.

The longer you wait, the more damage piles up. And once plaque hardens, you can’t undo it. You can only slow it down. That’s why early action matters more than anything.

New Treatments Are Changing the Game

For years, statins were the only real option. Now, things are changing fast.

In 2021, the FDA approved inclisiran (brand name Leqvio). It’s not a daily pill. You get two shots in the first year, then just twice a year after that. It works differently-targeting the liver’s production of LDL at the genetic level. It lowers LDL by about 50%, and because it’s so infrequent, adherence is much better.

There’s also better diagnosis. The Dutch Lipid Clinic Network Criteria now help doctors spot FH with 94% accuracy. That means fewer people slip through the cracks.

And science is moving toward personalized medicine. Polygenic risk scores can now tell you if your high cholesterol comes from dozens of small genetic tweaks-not just one big gene. That helps tailor treatment earlier, even if you don’t have FH.

The Bigger Picture: Why This Isn’t Just a Personal Problem

High cholesterol isn’t just about your health. It’s a public health crisis.

In the U.S., 94 million adults have total cholesterol above 200 mg/dL. The cost? $218 billion a year-$142 billion in medical bills, $76 billion in lost work. In England, the NHS reports only 48% of high-risk patients hit their LDL targets, even though statins are cheap and widely available.

Why? Because treatment requires consistency. People stop taking statins because of muscle aches, or because they feel fine, or because they forget. Only half stay on them after a year. That’s why new tools like once-every-six-months injections are such a big deal.

And the future? Obesity rates are rising. By 2030, half of U.S. adults could be obese. That means more diabetes, more metabolic syndrome, more secondary high cholesterol. We can’t treat our way out of this. We need better food systems, better education, better access to care.

What You Can Do Right Now

If you’re over 40, get a lipid panel. No excuses. It takes 10 minutes. No fasting. No needles beyond the usual blood draw.

If your LDL is above 160 mg/dL, ask your doctor about FH. Ask if your family has a history of early heart disease. Ask if you need genetic testing. Don’t assume it’s just diet.

If you’re on statins, don’t stop. If you’re having side effects, talk to your doctor. There are alternatives. Don’t give up because of muscle pain or fear.

And if you’re under 40 and have a family history? Get checked now. Don’t wait. Your future self will thank you.

High cholesterol isn’t a life sentence. It’s a signal. And signals are meant to be answered.