High Cholesterol
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High Cholesterol
Causes, cholesterol types, cardiovascular risk assessment, statins and UK treatment options.
Key fact: High cholesterol affects approximately 6 in 10 UK adults and is a leading modifiable risk factor for heart attack and stroke. It causes no symptoms — most people discover it only through a blood test. Statins, the cornerstone of treatment, reduce the risk of major cardiovascular events by 25–35% and are among the most evidence-backed medicines in medicine.
What Is Cholesterol?
Cholesterol is a fatty substance (lipid) produced by the liver and obtained from food. It is essential for normal body function — a key component of cell membranes, a precursor of steroid hormones (oestrogen, testosterone, cortisol), and needed for vitamin D and bile acid synthesis. The problem is not cholesterol itself but elevated levels of the wrong type circulating in the bloodstream.
Cholesterol is insoluble in water and is carried through the blood by proteins called lipoproteins. The type and quantity of these lipoproteins determines cardiovascular risk.
LDL, HDL and Triglycerides
| Lipid | Common name | Role | Cardiovascular risk | UK target |
|---|---|---|---|---|
| LDL cholesterol | “Bad” cholesterol | Carries cholesterol to body cells; excess deposits in arterial walls forming plaques | High — primary driver of atherosclerosis | <3 mmol/L general; <2 mmol/L high risk |
| HDL cholesterol | “Good” cholesterol | Removes cholesterol from arterial walls back to the liver | Protective — higher levels reduce risk | >1 mmol/L (men); >1.2 mmol/L (women) |
| Triglycerides | — | Energy storage fats; elevated in metabolic syndrome and diabetes | Moderate independent risk | <1.7 mmol/L fasting |
| Total cholesterol | — | Sum of all fractions | Useful screening measure | <5 mmol/L |
| Non-HDL cholesterol | — | Total minus HDL; captures all atherogenic particles | Increasingly preferred treatment target | <4 mmol/L general; <2.5 mmol/L high risk |
Causes and Risk Factors
Diet high in saturated fat
Saturated fat (red meat, full-fat dairy, butter, coconut oil, processed foods) raises LDL by reducing the liver's LDL receptor activity. Replacing it with unsaturated fat reduces LDL by 10–15%.
Familial hypercholesterolaemia (FH)
Inherited LDL receptor defect affecting 1 in 250 UK adults. Total cholesterol often exceeds 7.5 mmol/L. Requires early diagnosis and usually combination drug therapy — lifestyle changes alone are insufficient.
Diabetes and insulin resistance
Type 2 diabetes produces a characteristic dyslipidaemia: elevated triglycerides, reduced HDL, small dense LDL. Statin treatment is recommended for most people with type 2 diabetes regardless of baseline LDL.
Hypothyroidism
An underactive thyroid slows LDL receptor activity, raising LDL. Raised cholesterol with fatigue, weight gain and cold intolerance should prompt thyroid function testing — treating hypothyroidism often normalises cholesterol without statins.
Obesity and physical inactivity
Visceral fat raises triglycerides and lowers HDL. Regular aerobic exercise (150 minutes/week) raises HDL by 3–6% and reduces triglycerides independently.
Medicines
Corticosteroids, some antipsychotics, thiazide diuretics, beta-blockers and some antiretrovirals can raise cholesterol or triglycerides. Discuss alternatives with your prescriber before stopping any medication.
Symptoms
High cholesterol has no symptoms in the vast majority of people. It is entirely silent until it causes a cardiovascular event or is found on a blood test. This is why proactive screening matters.
In familial hypercholesterolaemia, very high sustained LDL levels may cause visible deposits:
- Xanthomas — firm yellowish cholesterol deposits on tendons (Achilles, extensor tendons of the hands)
- Xanthelasma — yellow plaques around the eyelids
- Corneal arcus — a white arc at the outer edge of the cornea (significant if under age 45)
Diagnosis and Target Levels
Cholesterol is measured by a blood test — fasting or non-fasting. Non-fasting samples are suitable for total cholesterol, HDL and non-HDL. Fasting is preferred for accurate triglyceride measurement.
NICE recommends cholesterol testing for: all adults aged 40+ (NHS Health Check), anyone with a family history of cardiovascular disease or FH, people with diabetes, hypertension or chronic kidney disease, and anyone with visible cholesterol deposits.
Cardiovascular Risk Assessment
Cholesterol levels alone do not determine treatment decisions. NICE recommends using QRISK3 to estimate 10-year cardiovascular risk. Treatment is based on overall risk, not cholesterol in isolation.
- 10-year CVD risk ≥10%: Offer statin treatment (atorvastatin 20mg first-line per NICE)
- Established CVD (secondary prevention): High-intensity statin (atorvastatin 80mg) regardless of baseline cholesterol
- Familial hypercholesterolaemia: Statin from diagnosis regardless of QRISK3 score
QRISK3 includes: age, sex, ethnicity, blood pressure, cholesterol ratio, BMI, smoking, family history, diabetes, chronic kidney disease, atrial fibrillation, systemic lupus, severe mental illness, antipsychotic use, and socioeconomic deprivation. A mildly elevated cholesterol in a 55-year-old smoker with hypertension carries very different implications from the same level in a healthy 35-year-old.
Lifestyle Changes That Lower Cholesterol
- Reduce saturated fat: Replace butter, cream and fatty meat with olive oil, rapeseed oil and lean protein
- Increase soluble fibre: Oats, barley, beans, lentils — binds bile acids in the gut; reduces LDL by 5–10%
- Plant stanols and sterols: Benecol, Flora ProActiv (2g/day reduces LDL by ~10%)
- Oily fish twice weekly: Omega-3s primarily lower triglycerides
- Exercise: 150 minutes moderate aerobic activity/week raises HDL and reduces triglycerides
- Stop smoking: Raises HDL by 5–10%; reduces oxidation of LDL
- Reduce alcohol: Heavy intake significantly raises triglycerides
- Lose weight: Each kg lost reduces LDL by approximately 0.02 mmol/L
Statins: How They Work
Statins inhibit HMG-CoA reductase, the rate-limiting enzyme in hepatic cholesterol synthesis. Reduced liver cholesterol production triggers upregulation of LDL receptors on the liver surface, dramatically increasing LDL clearance from the bloodstream.
Beyond LDL lowering, statins stabilise arterial plaques, reduce vascular inflammation, improve endothelial function and have antithrombotic effects. These pleiotropic effects may explain why statins reduce cardiovascular events even in people with normal baseline LDL but elevated inflammatory markers (CRP).
Statin Comparison
| Statin | Intensity | Typical dose | LDL reduction | NICE position |
|---|---|---|---|---|
| Atorvastatin | High | 20–80mg daily | 43–55% | First-line for primary and secondary prevention per NICE CG181 |
| Rosuvastatin | High | 10–40mg daily | 45–55% | Alternative when atorvastatin not tolerated |
| Simvastatin | Medium | 20–40mg daily | 32–40% | Long safety record; widely prescribed; available from Access Doctor |
| Pravastatin | Low–medium | 10–40mg daily | 20–34% | Fewer drug interactions; preferred in patients on multiple medicines |
| Fluvastatin | Low–medium | 20–80mg daily | 22–36% | Option for patients with intolerance to other statins |
Muscle symptoms: Muscle aching (myalgia) occurs in approximately 5–10% of statin users. True myopathy with elevated CK is rare. If you experience unexplained muscle pain, weakness or dark urine on a statin, contact your prescriber. Do not stop statins without medical advice — the cardiovascular benefit usually outweighs the risk of mild symptoms, and a switch to a different statin often resolves the problem.
Non-Statin Treatments
- Ezetimibe: Inhibits cholesterol absorption in the gut; adds 15–20% further LDL reduction on top of a statin; well tolerated
- PCSK9 inhibitors (evolocumab, alirocumab): Injectable monoclonal antibodies; reduce LDL by 50–60% on top of statins; NHS-funded for high-risk patients with specific criteria
- Inclisiran: Small interfering RNA given twice yearly by injection; reduces PCSK9 production; NICE-approved for high-risk patients
- Bile acid sequestrants (colesevelam, colestyramine): Reduce LDL 15–30%; usable in pregnancy; poorly tolerated due to GI side effects
- Fibrates (fenofibrate): Primarily lower triglycerides and raise HDL; used in severe hypertriglyceridaemia
Familial Hypercholesterolaemia (FH)
FH affects around 270,000 people in the UK but fewer than 10% are currently diagnosed. It is caused by a defective LDL receptor gene, resulting in lifelong severely elevated LDL from birth. Untreated, FH carries a 20-fold increased risk of premature coronary heart disease.
- Suspect FH if total cholesterol >7.5 mmol/L in an adult, or >6.7 mmol/L in a child
- Family history of MI before age 60 in a first-degree relative increases suspicion significantly
- Diagnose using Simon Broome or Dutch Lipid Clinic criteria; genetic testing identifies the mutation in ~80%
- Cascade screening of first-degree relatives is NHS-funded and recommended
- High-intensity statins should be started from diagnosis — do not delay for lifestyle changes alone
Get Cholesterol Treatment Online
Access Doctor provides prescription statin treatment — including simvastatin — following a confidential online cardiovascular risk assessment with our GPhC-registered pharmacist independent prescribers. No GP appointment required.
View Cholesterol Treatments →When to Seek Help
- You have not had a cholesterol test and are aged 40+, or have risk factors at any age
- Your total cholesterol is above 7.5 mmol/L, or a close relative has been diagnosed with FH
- You experience unexplained muscle pain, weakness or dark urine while taking a statin
- Your cholesterol is not reaching target despite statin therapy
- You have a family history of premature heart attack or stroke
Call 999 immediately if you experience chest pain, pain spreading to the jaw or arm, sudden shortness of breath, sudden weakness or numbness on one side, or sudden severe headache. These may indicate a heart attack or stroke requiring emergency treatment.
Related Guides
Frequently Asked Questions
What is high cholesterol?
High cholesterol means there is too much LDL cholesterol in the blood. Total cholesterol above 5 mmol/L is considered elevated in the UK. It is a silent condition — no symptoms — that significantly increases the risk of heart attack and stroke by promoting atherosclerosis (fatty plaque build-up in artery walls).
Does high cholesterol cause symptoms?
No — high cholesterol has no symptoms in the vast majority of people and is discovered through a blood test. Rare exceptions include familial hypercholesterolaemia, where very high cholesterol causes visible deposits: xanthelasma around the eyes, xanthomas on tendons, or a white arc at the cornea edge.
What are statins and how do they work?
Statins inhibit HMG-CoA reductase, the key enzyme in cholesterol synthesis in the liver. This causes the liver to draw more LDL from the bloodstream, lowering LDL by 30–55%. Statins also stabilise arterial plaques and reduce vascular inflammation, providing cardiovascular benefits beyond LDL lowering alone.
What lifestyle changes lower cholesterol?
Replacing saturated fat with unsaturated fat, increasing soluble fibre (oats, beans), adding plant stanols and sterols, exercising regularly, stopping smoking and losing weight can together reduce LDL by 10–20%. These changes complement statin therapy for high-risk individuals.
Do I need to take statins for life?
For most people prescribed statins for cardiovascular risk reduction, long-term treatment is recommended as the benefit wanes on stopping. This should be reviewed regularly with your prescriber. Do not stop statins without medical advice — the risk reduction is continuous only while taking them.
Can I get statin treatment online in the UK?
Yes. Access Doctor provides prescription statins including simvastatin following a confidential online cardiovascular risk assessment with our GPhC-registered pharmacist independent prescribers. A full review of your cholesterol results and medical history is carried out before any prescription is issued.
References
- National Institute for Health and Care Excellence (NICE). Cardiovascular disease: risk assessment and reduction, including lipid modification. NICE guideline CG181. Updated 2023. nice.org.uk/guidance/cg181
- NHS. High cholesterol. NHS.uk, 2023. nhs.uk/conditions/high-cholesterol
- HEART UK. Familial hypercholesterolaemia. heartuk.org.uk
- Cholesterol Treatment Trialists’ Collaboration. Effects of lowering LDL cholesterol with statin therapy in people at low risk of vascular disease. Lancet. 2012;380(9841):581–590.
Medical disclaimer: This article is for informational purposes only and does not constitute medical advice. Always consult a qualified healthcare professional for diagnosis and treatment. In a medical emergency, call 999.
