Warning Signs of High Cholesterol 

If too much LDL cholesterol circulates in the blood, it can lodge in the artery walls, where it combines with other substances to form plaque. Over time, the buildup causes arteries to narrow and become less flexible (a condition known as atherosclerosis), leading to a heart attack or stroke. It's estimated that 1 in 4 U.S. adults has high LDL levels. 

“Atherosclerosis is a systemic disease — not just a ‘heart’ disease but a cardiovascular disease that affects blood vessels in multiple areas of the body, from your head to your toes,” says Dr. Matthew Tomey, a cardiologist and faculty member at Mount Sinai Fuster Heart Hospital in New York.

High cholesterol “can contribute to the risk of disease in all these areas, with consequences ranging from stroke to heart attack to intestinal ischemia and abdominal pain, to leg pain and limb loss,” he adds.

What are the risk factors for high cholesterol?

Lifestyle plays a huge role. Smoking, drinking to excess, being physically inactive and eating a diet rich in saturated fats all raise your risk for high cholesterol.

Age also figures in. As you get older, your liver becomes less efficient at removing LDL cholesterol from your blood. Plus, hormonal shifts and an increased likelihood of chronic conditions (like diabetes, kidney disease, sleep apnea and liver disease) can affect cholesterol levels.

“If you have a family history of very high cholesterol from a young age or heart attacks at a young age, checking your cholesterol levels and discussing them with a knowledgeable physician is crucial,” says Dr. Ashish Sarraju, a preventive cardiologist at the Cleveland Clinic. The latest guidelines recommend screening children as young as 9 to detect high cholesterol caused by inherited conditions or lifestyle factors.

“High cholesterol isn’t just about the heart,” says Sarraju. There are risks for strokes or transient ischemic attacks (TIAs, sometimes called ministrokes), he explains. “If someone has high cholesterol, they may be at higher risk for vascular dementia due to disease in the small arteries supplying the brain.”

The peripheral arteries are also important, he adds. “High cholesterol can be associated with blockages in the arteries of the legs, predisposing people to pain with walking or foot ulcers.”

Treating high cholesterol

Depending on your specific risk factors, your doctor may first recommend lifestyle changes before prescribing medication.

“Lifestyle changes are a powerful foundation for cholesterol management, cardiovascular risk reduction and overall health,” says Martin. “Getting regular exercise and eating a heart-healthy diet that’s low in saturated and trans fats can often significantly lower LDL cholesterol and triglycerides.”

And losing weight — even just 5 to 10 percent of your overall body weight — can improve your cholesterol numbers, he adds.

If lifestyle changes don’t sufficiently lower your cholesterol, your doctor may prescribe medication.

“While we want to try to optimize healthy lifestyle habits as the first step to lower cholesterol, we realize that if lipid numbers aren’t within the desirable range after a period of lifestyle optimization, we should consider adding lipid-lowering medication earlier than we would have considered 10 years ago,” said Dr. Roger Blumenthal, chair of the latest guideline writing committee and director of the Johns Hopkins Ciccarone Center for the Prevention of Heart Disease. “And lower LDL cholesterol for longer, just like lower blood pressure for longer, results in much greater protection against future heart attack and stroke risk.”

Cholesterol-lowering medication used to almost automatically mean statins — a type of medication that lowers LDL by blocking the enzyme your liver needs to make cholesterol — but that’s no longer necessarily the case.

“Treatment has evolved from focusing solely on diet to having powerful medications that lower LDL cholesterol and lower cardiovascular risk,” says Martin.

“Statins became the first-line medications starting in the 1980s, and more recently, there has been the introduction of multiple, effective non-statin medications,” he says. “For instance, ezetimibe, PCSK9 inhibitors, bempedoic acid — with a combination treatment approach becoming more common.”

Preventing high cholesterol

Maintaining a heart-healthy lifestyle can go a long way toward keeping your cholesterol levels in check. The American Heart Association recommends limiting saturated fat to less than 6 percent of daily calories and avoiding trans fats altogether.

Aim for at least 150 minutes per week of moderate-intensity aerobic exercise (like brisk walking, swimming, cycling), and give up smoking and vaping (by quitting, you can lower your triglycerides and increase your HDL levels).

“Sometimes, it is hard to convince [a patient] that they need to aggressively change their lifestyle or start medications if they feel fine,” says Sarraju. “But we don’t want to wait for symptoms of high cholesterol — typically that means a coronary event or stroke. We want to make changes years or decades before this can happen.”

Citing the findings of a landmark study published in The New England Journal of Medicine showing a nearly 50 percent reduced risk of coronary artery disease in adults at a high genetic risk who maintained a healthy lifestyle, Tomey says: “We can all benefit from a healthy diet and lifestyle — even if genetics predispose to high cholesterol or cardiovascular disease.”