What is hyperlipidemia (High cholesterol)? 

Hyperlipidemia is a term to describe a medical condition whereby the blood levels of cholesterol are raised. The cholesterol refers to the bad cholesterol which are triglycerides and low-density lipoprotein cholesterol (LDL-C). 

Combined hyperlipidemia refers to the condition whereby the total cholesterol and triglycerides are both raised. 

​Dyslipidaemia is a wider terminology that also includes low levels of good cholesterol namely the high-density lipoprotein cholesterol (HDL-C). 

Familial Hypercholesterolemia is a autosomal dominant condition whereby the total cholesterol and LDL are raised. In untreated patients, xanthomas may appear on the archilles tendon and the metacarpal phalangeal extensor tendons.   

Having high levels of cholesterol will narrow the blood vessels with plaque (clot formation ) and increase risk of cardiovascular disease like heart diseases, stroke and peripheral vascular disease. Besides hyperlipidemia other risk factors for cardiovascular disease include hypertension, smoking, diabetes, kidney disease, increasing age, strong family history of heart diseases and male gender. 
Types of lipid in lipid profile test

You have to do a fasting lipid blood test in order to know if you have high cholesterol (hyperlipidemia). The blood test will measure the lipoproteins levels which are different types of lipids in your blood to interpret the results. 

1. Total cholesterol when raised increased your risk of getting cardiovascular diseases. 
  • A total cholesterol level of less than 200 mg/dL (5.17 mmol/L)is normal.
  • A total cholesterol level of 200 to 239 mg/dL (5.17 to 6.18mmol/L) is borderline high.
  • A total cholesterol level greater than or equal to 240 mg/dL(6.21 mmol/L) is high.

2. LDL ( Low Density Lipoprotein ) : is the bad cholesterol which is a better predictor than total cholesterol. Higher levels of LDL has been highly associated with cardiovascular diseases. Framingham score predicts the 10 year risk of cardiovascular disease. 
  • For High risk patients the level of LDL should be below 2.6 mmol/L 
  • For Moderate risk patients the level of LDL should be below 3.4 mmol/L 
  • For Low Risk patients the level of LDL should be below 4.1 mmol/L 

​3. Triglycerides : is the bad cholesterol that will also increased risk of cardiovascular diseases when raised. 
  • Normal - less than 150 mg/dL (1.69 mmol/L)
  • Borderline high - 150 to 199 mg/dL (1.69 to 2.25 mmol/L)
  • High - 200 to 499 mg/dL (2.25 to 5.63 mmol/L)
  • Very high - greater than 500 mg/dL (5.65 mmol/L)

​4. HDL cholesterol : is the good cholesterol ; when raised is actually protective against cardiovascular diseases. 
  • Level greater than or equal to 60 mg/dL or 1.55 mmol/L is good 
  • Levels less than 40 mg/dL or 1.03 mmol/L are lower than desired​
Causes and symptoms of Hyperlipidemia 

In the early stages , there are no symptoms that the person with high cholesterol will feel. When the triglycerides are highly raised there will be a risk of pancreatitis and patient may experience extreme epigastric pain , nausea, vomiting , fever and even jaundice. But when cardiovascular complications come in , he may experience chest pain (heart diseases), leg pain and gangrene ( peripheral vascular disease ), numbness and weakness ( stroke). 

In familial hypercholesterolaemia there may be physical signs like : 
  • Premature arcus senilis - a white/ gray opaque ring in the corneal margin
  • Tendon xanthomata - hard nodular enlargement of tendons, more commonly found on the knuckles and the Achilles tendons.​
​Causes of hyperlipidemia can be due to familial genetic inherited condition, high fat diet, sedentary lifestyle , obesity, diabetes , alcoholism and physiological state like in pregnancy. 
Non medical treatment 

1. Well balanced healthy diet : 
  • Healthy diet helps you to lose weight and lower bad cholesterol.  
  • Reduce Saturated and Trans Fats 
  • Eat more portions of fruits and vegetables 
  • Eat whole grains like brown rice and oats
  • Reduce foods that are rich in bad cholesterol like internal organs, egg yolks, crabs, oysters 
  • Increase high fiber foods like oats, barley, vegetables and fruits 
  • Eat more healthy fish like salmon, tuna and herring. 

2. Exercise : benefits of exercise include lowering of blood pressure, reduce bad cholesterol, increase good cholesterol, lose weight and reduce risk of death from cardiovascular disease. Recommended amount of exercise is 30 minutes of moderate exercise at least 5 times a week. 

3. Losing weight : Obesity increases bad cholesterol and risk of cardiovascular diseases. Losing weight will help reduce LDL and Triglycerides and also increase good cholesterol HDL. 
Medical Treatment for hyperlipidemia 

If the cholesterol levels still high despite diet and exercise regimes , to prevent risk of cardiovascular diseases , medications will be started as benefits outweighs risk. There are different groups of medications that can be used for hyperlipidemia treatment. They are: 

1. Statins 
  • Statins are HMG-COA inhibitors which inhibit the pathway of cholesterol production
  • It can effectively reduce LDL by 20-60% , it can also increase HDL and reduce triglycerides 
  • Common statins that are widely used are simvastatin, lovastatin, atorvastatin, rosuvastatin 
  • Some side effects include myositis (muscle inflammation) , joint pain and transaminitis (mild derangement of liver enzymes). Liver and kidney damage is very rare. 
  • Statins are unsafe in pregnant ladies. 

2. Nicotinic Acid (Niacin)
  • Is a vitamin that can increase HDL, reduce LDL and as an adjunct for patients who still can't control their cholesterol levels despite on other cholesterol lowering medicines. 
  • Side effects include flushing of skin (which can be reduced by taking aspirin 30 minutes before niacin), nausea, numbness and tingling, increase in sugar levels in diabetics, increase uric acids in gout patients and transaminitis (mild derangement of liver enzymes)
  • Do not take niacin as a health supplement 
​
3. Fibrates 
  • Fibric acid derivatives medications like gemfibrozil, fenofibrates can lower triglycerides and raise HDL 
  • Some side effects include myositis (muscle inflammation) especially in renal patients or when in combination with statins ,sun-sensitivity, stomach pain, gallstones and transaminitis (mild derangement of liver enzymes). Very rarely causes autoimmune hepatitis and liver damage. 
4. Ezetimibe
  • Inhibits intestinal absorption of cholesterol from food in the small intestines
  • Lowers LDL 
  • Side effects include muscle weakness, nausea and headache
  • As ezetimibe does not induce or inhibit liver enzymes , it has minimal transaminitis unless combined with statins
5. Bile acid binding resins
  • Medications like cholestyramine , colesevelam and colestipol binds to bile acids in intestine and reduces absorption of cholesterol from food
  • It also indirectly reduces cholesterol by up-regulating conversion of cholesterol into bile acids in liver cells 
  • Lowers LDL
  • Safe liver profile 
  • Side effects include bloatedness, cramping, nausea and constipation
  • It can interact with cardiac drugs like digoxina nd warfarin
6. PCSK9 inhibitors
  • These are newer class of medications  like alirocumab and evolocumab that can lower LDL and other lipoproteins 
  • More studies needed to evaluate its possible side effects
Health supplements which may help lower bad cholesterol 

1. Soy Protein 
  • Soy protein like tofu and miso can lower total levels of cholesterol , LDL , triglycerides and raise HDL 
  • However soy proteins contain isoflavones with estrogen-like effects in body when over consumed may increase a slight risk of breast and other cancers. 
2. Omega-3
  • Omega-3 is fish oil that we can obtain from eating fish like salmon, sturgeon, mackerel, tuna, anchovy, sardines, mullet, herring, trout, bluefish, and menhaden. 
  • Two most important omega-3 fatty acids contained in fish oil are eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). 
  • There are research conducted to prove that omega-3 helps reduce triglycerides (bad cholesterol), prevent heart disease and artherosclerosis, prevent age related macular degeneration ( an eye condition), prevent re-blockage of arteries post heart attack, prevent miscarriages in patients with anti-phospholipid syndrome, improves psychiatric disorders (e.g. bipolar disease, ADHD and psychosis), improves menstrual pain, improves blood pressure, improves IGA nephropathy , helps in osteoporosis and improves autoimmune diseases like raynaud's phenomenon and rheumatoid arthritis. 
  • At normal dosing of 3 grams anad below it is safe for most people including pregnant and lactating women. 
​3. Red Yeast 
  • Red yeast is a health supplement that is formed from rice fermented with monascus purpureus yeast to produce chemicals which is similar to anti-cholesterol drugs statins that help lower bad cholesterol (LDL and Triglycerides). 
  • There are research conducted to prove that lactobacillus help to reduce bad cholesterol (LDL and triglycerides) and reduce the risk of heart diseases. 
  • At normal dosing it is safe for most people. Pregnant and lactating woman should not take red yeast as it is unsafe. 
  • As red yeast contain similar contents like statins it may have similar possible side effects like statins. This include muscle pain (myalgia), muscle damage (only at very high doses as per statins) and transaminitis (liver inflammation at very high doses just like statins). 
  • Patients with liver diseases should avoid red yeast as like statins it may worsen the liver function.​