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Does High Cholesterol Always Need Medication?

Medically Reviewed by Neha Pathak, MD on June 09, 2021

If you’re diagnosed with high cholesterol, will you need to start taking a statin or other medication? Not always.

High cholesterol can affect your cardiac risk, or the chance that you’ll develop heart disease. Other things, including your age, weight, smoking habits, and family history, may affect your cardiac risk, too.

Your doctor will assess your cardiac risk based on your exam, medical history, and tests. This information will help you and your doctor decide how to treat your high cholesterol: with a healthy diet and exercise alone, or with lifestyle changes and medication.

Understanding Cholesterol

Cholesterol is a type of lipid, a fatty, waxy substance in your blood. High amounts of cholesterol can build up inside your arteries. This can clog and narrow your arteries so blood can’t flow easily. Blood clots can form, break away, and cause a stroke or heart attack.

There are two main types of cholesterol:

  • Low-density lipoprotein (LDL), or “bad cholesterol.” If your LDL level is too high, you’re at greater cardiac risk. LDL is the cholesterol that clumps up and clogs your arteries.
  • High-density lipoprotein (HDL), or “good cholesterol.” More of this cholesterol can clear out LDL cholesterol. That can lower your cardiac risk and protect your heart.

Triglycerides are another kind of blood lipid. They store extra calories from your food that your body can use for energy. Like high cholesterol, high triglycerides can harden your arteries and lead to a heart attack or stroke.

A blood lipid profile test measures your cholesterol and triglycerides. Healthy numbers are:

  • Total cholesterol: below 200 milligrams per deciliter (mg/dL)
  • LDL cholesterol: less than 130 mg/dL, or less than 100 mg/dL if you have heart disease or diabetes, or less than 70 mg/dL if you’ve had a heart attack or stroke
  • HDL cholesterol: above 50 mg/dL for females and 40 mg/dL for males
  • Triglycerides: below 150 mg/dL

Types of High Cholesterol

There are different types of high cholesterol, based on what’s causing it:

Primary high cholesterol is also called familial hypercholesterolemia (FH). It’s when high cholesterol runs in your family. You may have very high levels of LDL cholesterol, which puts you at high risk of heart disease, even at a younger age.

How it’s treated: A low-fat diet, regular exercise, and staying at a healthy weight are part of a good plan to reduce high cholesterol. People with genetic high cholesterol likely will also need to treat it with medications, usually a statin. Other medications could include nicotinic acid (niacin) to lower your LDL and raise your HDL, bile acid-binding drugs, fibrates, or ezetimibe (Zetia) in combination with a statin.

If these treatments don’t lower your LDL, PCSK9 inhibitors (Praluent, Repatha) are a newer treatment option for FH. They block a protein to help lower LDL in your blood.

Secondary high cholesterol is linked to health conditions like diabetes, heavy drinking, chronic kidney disease, hypothyroidism, and a high-fat diet or lack of exercise. Certain drugs for other medical conditions, like steroids, can cause high cholesterol, too.

How it’s treated: Most people with high LDL cholesterol not caused by genetics don’t treat it with medications at first. Instead, you can try eating a heart-healthy diet, getting more exercise, quitting smoking, and losing weight if you’re overweight. If those steps don’t work, you may need medication. You may start with a statin, and if that doesn’t help you reach your LDL goal, you may add other medicine, like ezetimibe (Zetia), PCSK9 inhibitors, niacin, fibrates, and omega-3 fatty acid supplements.

High triglycerides may be caused by an unhealthy diet, obesity, diabetes, heavy drinking, kidney disease, or hypothyroidism. For some people, high triglycerides can be genetic.

How they’re treated: Usually, high triglycerides are treated with a heart-healthy diet, cutting back on saturated fats and trans fats, exercise, avoiding alcohol, and weight loss if you’re overweight. If these lifestyle changes don’t lower your numbers enough, your doctor may prescribe nicotinic acid, fibrates, or omega-3 fatty acid supplements. Statins may help if you also have high LDL cholesterol, heart disease, or diabetes.

Low HDL cholesterolmay be caused by smoking, HIV infection, uncontrolled diabetes, or some kidney problems. Some drugs may lower your HDL as a side effect, including beta-blockers and steroids.

How it’s treated: First, try to increase your HDL with a heart-healthy diet that’s low in trans fats and saturated fats. Get plenty of exercise, avoid smoking, and limit alcohol to one drink per day if you’re a woman or two drinks per day if you’re a man. If that doesn’t work, your doctor may prescribe medicines that help lower LDL and, in some cases, raise HDL. But evidence doesn’t show that increasing HDL with medicines changes your risk for heart disease. Your doctor may prescribe niacin, fibrates, or statins like rosuvastatin (Crestor) or simvastatin (Zocor).

How to Know if You Need Treatment

Everyone with high cholesterol should start with heart-healthy lifestyle changes like diet, exercise, quitting smoking, and weight loss. But if your cardiac risk is high, you may need treatment with medications, too.

Your doctor can use a formula to calculate a score that shows your risk of a heart attack in the next 10 to even 30 years.

Your cardiac risk is based on a combination of these things:

  • Total, LDL, and HDL cholesterol
  • Blood pressure
  • Age
  • Race
  • Sex
  • Smoking habit or past smoking habit
  • Diabetes
  • Heart disease or family history of early heart disease

You may not need to treat high cholesterol with medications like statins now if you are:

  • 19 or younger and don’t have FH
  • 20-39, with no family history of early heart disease, and your LDL is below 160 mg/dL
  • 40-75, and your cardiac risk is low (less than 5%)
  • 40-75, and your cardiac risk is borderline (5% to less than 7.5%)
  • 40-75, and your cardiac risk is intermediate (7.5% to less than 20%)
  • 75 or older
  • Pregnant
  • Have advanced liver disease

If your cardiac risk score is borderline or intermediate: Your doctor may talk with you about the risks and benefits of cholesterol-lowering drugs, including possible side effects.

Ask yourself if you’re ready to stick with a healthy diet, weight loss, and exercise. If you’re not, you may want to treat high cholesterol with medication.

If your cardiac risk is intermediate or unclear, but you’re not sure if you want to take medication to treat your high cholesterol, your doctor may suggest one of these heart disease screening tests:

Coronary calcium scan

A coronary calcium scan is a CT scan that checks for the buildup of plaque that contains calcium in your heart’s arteries. That plaque can harden the arteries. Your heart may not be able to get the blood it needs to work the way it needs to.

A coronary calcium scan can assess your risk of coronary artery disease (CAD) before you have any signs or symptoms. This scan can help your doctor tell if you need cholesterol medications or just lifestyle changes to prevent a heart attack.

High-sensitivity CRP

A high-sensitivity C-reactive protein blood test, or hs-CRP, checks for inflammation.

It can measure your heart disease risk to help you and your doctor decide if you need to start treatment. If your hs-CRP is more than 3.1 milligrams per liter (mg/L), then your actual risk of heart disease may be higher than your cardiac risk score suggests. This test can also predict your risk of a second heart attack if you’ve already had one.

WebMD Medical Reference

Sources

SOURCES:

Mayo Clinic: “High Cholesterol,” “Triglycerides: Why do they matter?” “HDL: How to boost your ‘good’ cholesterol,” “Statins: Are these cholesterol-lowering drugs right for you?” “Heart Scan (Coronary Calcium Scan),” “C-reactive protein test.”

LabTestsOnline: “Cardiac Risk Assessment.”

Carle Health: “High Triglycerides.”

Hormone Health Network: “Hyperlipidemia.”

National Organization for Rare Disorders: “Familial Hypercholesterolemia.”

Merck Manual: “Dyslipidemia,” “Dyslipidemia (Hyperlipidemia).”

The Hormone Foundation: “Types of Hypercholesterolemia Medications You Should Know.”

American College of Cardiology: “ASCVD Risk Estimator Plus.”

Circulation: “2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol.”

Kaiser Permanente of Washington: “Atherosclerotic Cardiovascular Disease (ASCVD) Primary Prevention Guideline.”

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