High cholesterol and lipid metabolism disorder: causes, risk & modern treatment

1. What is high cholesterol?

Cholesterol is a vital component of every body cell. The body produces most of it itself; some is taken in through food. It becomes a problem when LDL cholesterol (colloquially: bad cholesterol) is permanently elevated — because LDL deposits in the vessel walls and promotes atherosclerosis (vascular calcification).^¹

Elevated LDL cholesterol is one of the most important modifiable risk factors for heart attack, stroke and other cardiovascular diseases. The evidence for this is clear according to current knowledge: the lower the LDL cholesterol, the lower the risk — the ESC/EAS guideline (Focused Update 2025) frames it as a basic principle.^¹

2. LDL, HDL, triglycerides — what do the values mean?

• LDL cholesterol: transports cholesterol into the vessels and deposits it there. Elevated values promote atherosclerosis. The most important target value of treatment.^¹
• HDL cholesterol: transports excess cholesterol back to the liver (a protective function). Low values are considered a risk factor. According to current knowledge, however, there is no medication that lowers the cardiovascular risk by raising HDL.
• Triglycerides: blood fats that rise with excess energy intake (especially sugar, alcohol, excess weight). Strongly elevated triglycerides can increase the cardiovascular risk and in rare cases trigger an acute pancreatitis.
• Total cholesterol: the sum of LDL, HDL and VLDL. Often measured, but less informative than LDL cholesterol alone.
• Lipoprotein(a) (Lp(a)): a genetically determined risk factor that was included as a risk modifier in the ESC/EAS update 2025. It is usually measured once in a lifetime. It can currently barely be influenced by medication — new therapies are in development.

3. Causes and risk factors

• Diet: a high proportion of saturated fatty acids (fatty meat, sausage, cheese, butter, coconut fat) and trans fatty acids (fried food, baked goods, ready-made products) can raise LDL.
• Lack of exercise: a sedentary lifestyle.
• Excess weight: obesity usually raises LDL and triglycerides and lowers HDL.
• Genetics: familial hypercholesterolaemia (FH) is a common genetic condition that leads to strongly elevated LDL values already at a young age. It is often not recognized (see the separate section below).
• Other conditions: hypothyroidism, chronic kidney disease, type 2 diabetes, liver diseases.
• Medications: certain medications can affect lipid metabolism (e.g. cortisone, beta blockers, thiazides, immunosuppressants).

4. Symptoms

With very strongly elevated values (especially with familial hypercholesterolaemia), visible signs can appear:

• Xanthomas: cholesterol deposits in tendons or under the skin
• Xanthelasmas: yellowish deposits on the eyelids
• Arcus lipoides: a whitish ring around the cornea

These signs are rare but diagnostically telling — they should prompt consideration of a familial form.

5. Diagnosis and risk assessment

• Lipid profile: total cholesterol, LDL, HDL, triglycerides — usually fasting or non-fasting (the results are comparable for most values). LDL is the decisive target value.
• Risk assessment: the ESC/EAS guideline recommends an individual risk assessment — in the 2025 update with SCORE2 (for ages 40–69) and SCORE2-OP (for ages 70–89). The overall risk determines the LDL target values and the treatment intensity.^¹
• LDL target values (ESC/EAS 2025): depend on the individual cardiovascular risk. The higher the risk, the lower the target value. For people with existing cardiovascular disease or a very high risk, the lowest target values usually apply.^¹
• Lipoprotein(a): recommended as a risk modifier in the 2025 update — it should usually be measured once in a lifetime.

More: Preparing for a doctor's appointment, Understanding your blood values.

6. Treatment: lifestyle

Lifestyle changes are the basis of every cholesterol treatment — regardless of whether medications are used.^¹

• Reduce saturated fatty acids — less fatty meat, sausage, cheese, butter, coconut fat; instead unsaturated fatty acids (olive oil, nuts, avocado, oily fish)
• Avoid trans fatty acids — fried food, industrial baked goods, ready-made products
• Increase fibre — wholegrain products, vegetables, legumes, fruit
• Normalize weight with excess weight
• Regular exercise — can lower LDL and raise HDL
• Stopping smoking — smoking damages the blood vessels independently of cholesterol
• Reduce alcohol — can lower triglycerides

7. Treatment: medications

When lifestyle changes alone are not enough to reach the individual LDL target values, medications are used. The decision depends on the overall risk.^¹

8. Familial hypercholesterolaemia

Familial hypercholesterolaemia (FH) is a common genetic condition that leads to strongly elevated LDL values — already at a young age and independently of lifestyle. The heterozygous form affects, by estimates, about one in several hundred people but is usually considerably underdiagnosed.^¹

• Suspected with clearly elevated LDL (especially at a younger age), a positive family history (heart attack or stroke in relatives before the age of 55 (men) or 60 (women)), xanthomas
• Diagnosis: clinical scoring systems (e.g. the Dutch Lipid Clinic Network Score) and/or genetic testing
• Treatment: early and consistent LDL lowering (statins + ezetimibe, if needed PCSK9 inhibitors); lifestyle change alone is usually not enough with FH
• Cascade screening: first-degree relatives should also be tested

How brite helps you with high cholesterol

A statin in the evening, ezetimibe with it, a new LDL result every three months and the question of whether the target has been reached — plus high blood pressure and diabetes in the background. Cholesterol treatment is often part of a larger cardiovascular plan. brite keeps it clear.

• Medication reminder — a statin in the evening, ezetimibe or bempedoic acid in the morning: brite reminds you on time. Precisely because statins are taken for life, a routine helps. Set up a reminder
• Interaction check — a statin plus grapefruit juice? Plus macrolide antibiotics? Plus certain antifungals? brite shows when statin levels can rise unintentionally — and with them the risk of muscle side effects. Check now
• Health history — document LDL, HDL, triglycerides and total cholesterol over time. That way you can clearly see whether the treatment reaches the LDL target — or whether an escalation would make sense. Track your history
• Digital medication plan — all your medications clearly laid out for cardiology, your family doctor and the lipid clinic. Helps especially when, alongside the statin, blood pressure lowering drugs and antidiabetics are added. Go to medication plan

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