Hypercholesterolaemia

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Last reviewed: 21 Jun 2025

Last updated: 15 Jan 2025

Hypercholesterolaemia is most commonly, but not exclusively, defined as elevated levels of low-density lipoprotein cholesterol (LDL-C) or non-high-density lipoprotein cholesterol (non-HDL-C); an alternative term is dyslipidaemia, which encompasses elevated triglycerides, low levels of HDL-C, and qualitative lipid abnormalities.

Hypercholesterolaemia is an important risk factor for atherosclerotic cardiovascular disease, including cerebrovascular disease, coronary heart disease, and peripheral arterial disease; it is usually symptomatically quiescent until significant atherosclerosis has developed.

Complications of hypercholesterolaemia and atherosclerosis include myocardial infarction, ischaemic cardiomyopathy, sudden cardiac death, ischaemic stroke, erectile dysfunction, claudication, and acute limb ischaemia.

Risk factors for secondary hypercholesterolaemia include a sedentary lifestyle and a diet characterised by the excessive consumption of saturated fats, trans-fatty acids, and cholesterol. Other associations include diabetes, excess body weight mainly in the abdominal region, hypothyroidism, nephrotic syndrome, and cholestatic liver disease. Low HDL-C levels are associated with smoking and abdominal obesity.

Hypercholesterolaemia is diagnosed by a lipid profile, consisting of measurements of total cholesterol, LDL-C (estimated or direct), HDL-C, and triglycerides. Non-HDL-C is calculated by the subtraction of HDL-C from total cholesterol.

Hypercholesterolaemia is treated with lifestyle modifications such as dietary changes, exercise, and smoking cessation, as well as pharmacological intervention with statin therapy and selective use of other lipid-lowering drugs.

Definition

Hypercholesterolaemia, an elevation of total cholesterol (TC) and/or LDL-C or non-HDL-C (defined as the subtraction of HDL-C from TC) in the blood, is also often referred to as dyslipidaemia, to encompass the fact that it might be accompanied by a decrease in HDL-C, an increase in triglycerides, or qualitative lipid abnormalities. Dyslipidaemia is classified as serum TC, LDL-C, triglycerides, apolipoprotein B, or lipoprotein(a) concentrations above the 90th percentile, or HDL-C or apolipoprotein A-I concentrations below the 10th percentile for the general population. However, these classic percentile cut-off points should not be used too rigidly in defining dyslipidaemia. For example, evidence suggests that lipoprotein(a) ≥80th percentile is abnormal and linked to elevated cardiovascular risk.[1]

History and exam

Key diagnostic factors

presence of risk factors
family history of early onset of coronary heart disease or dyslipidaemia in first-degree relatives
history of cardiovascular disease
consumption of saturated fats and trans-fatty acids
excess body weight (especially abdominal obesity)
xanthelasmas
tendinous xanthomas

Full details

Other diagnostic factors

arcus cornealis with onset before the age of 45 years
tuberous xanthomas

Full details

Risk factors

insulin resistance and type 2 diabetes mellitus
excess body weight (body mass index >25 kg/m²)
cigarette smoking
hypothyroidism
cholestatic liver disease
nephrotic syndrome
use of certain medications

Full details

Diagnostic investigations

1st investigations to order

lipid profile
serum thyroid-stimulating hormone (TSH)
lipoprotein(a)

Full details

Investigations to consider

genetic testing

Full details

Treatment algorithm

ACUTE

with clinical ASCVD: very high risk

with clinical ASCVD: not very high risk and age ≤75 years

with clinical ASCVD: not very high risk and age >75 years

without clinical ASCVD: LDL-C ≥4.9 mmol/L (≥190 mg/dL) without diabetes mellitus (age 20-75 years)

without clinical ASCVD: LDL-C ≥4.1 mmol/L (≥160 mg/dL) without diabetes mellitus (age 20-39 years)

without clinical ASCVD: LDL-C 1.8 to 4.9 mmol/L (70-189 mg/dL) without diabetes mellitus (age 40-75 years)

without clinical ASCVD: LDL-C 1.8 to 4.9 mmol/L (70-189 mg/dL) without diabetes mellitus (age >75 years)

without clinical ASCVD: with diabetes mellitus and risk enhancers (age 20-39 years)

without clinical ASCVD: with diabetes mellitus, 10-year ASCVD predicted risk <7.5% and no risk factors (age 40-75 years)

without clinical ASCVD: with diabetes mellitus, 10-year ASCVD predicted risk ≥7.5% and risk enhancers (age 40-75 years)

without clinical ASCVD: with diabetes mellitus (age >75 years)

ONGOING

familial hypercholesterolaemia

Contributors

Authors

Thorsten Leucker, MD, PhD

Assistant Professor of Medicine

Division of Cardiology, Department of Medicine

Johns Hopkins University School of Medicine

Baltimore

Disclosures

TL has received grant funding for his university from Amgen and Merck.

Richard A. Ferraro, MD

Cardiovascular Disease Fellow

Division of Cardiology, Department of Medicine

Johns Hopkins University School of Medicine

Baltimore

Disclosures

RAF declares that he has no competing interests.

Acknowledgements

Dr Thorsten Leucker and Dr Richard A. Ferraro would like to gratefully acknowledge Dr Seth S. Martin, Dr Rhanderson Cardoso, Dr Raul D. Santos, Dr Martin Engelhardt, and Dr Michael Miller, the previous contributors to this topic.

Disclosures

SSM has received honoraria from the American College of Cardiology for educational activities. SSM is listed as a co-inventor on a pending patent filed by Johns Hopkins University for a novel method of LDL-cholesterol estimation. SSM received a charitable gift for the VLDL big data project from the David and June Trone Family Foundation, and has also received research support from the PJ Schafer Cardiovascular Research Fund, American Heart Association, Aetna Foundation, iHealth, Stanford MedX/Nokia, Google, and Apple. SSM has acted as a consultant for Abbott Nutrition, Pressed Juicery, Quest Diagnostics, Sanofi/Regeneron, Amgen, Novo Nordisk, Esperian, Akcea, and the Pew Institute. RC declares that he has no competing interests. RDS has received honoraria for consulting, speaker activities and research from Astra Zeneca, Amgen, Akcea, Biolab, Esperion, Kowa, Pfizer, Merck, Novo-Nordisk, and Sanofi/Regeneron. ME declares that he has no competing interests. MM has received research grant support and honoraria for lectures from AstraZeneca, Merck-Schering Plough, and Pfizer. MM has received consulting fees from Pfizer, Merck-Schering Plough, and Roche.

Peer reviewers

Mahi Lakshmi Ashwath, MD

Assistant Professor of Medicine

Noninvasive Cardiology

MetroHealth Campus

Case Western Reserve University

Cleveland

Disclosures

MLA declares that he has no competing interests.

Deepak Bhatnagar, TD MBBS PhD FRCP FRCPI FRCPath

Consultant/Senior Lecturer in Diabetes & Metabolism

The Royal Oldham Hospital & University of Manchester Cardiovascular Research Group Diabetes Centre

Royal Oldham Hospital

Oldham

Disclosures

DB declares that he has no competing interests.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

Mach F, Baigent C, Catapano AL, et al. 2019 ESC/EAS guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk. Eur Heart J. 2020 Jan 1;41(1):111-88.Full text Abstract

Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019 Jun 18;139(25):e1082-143.Full text Abstract

National Institute for Health and Care Excellence. Cardiovascular disease: risk assessment and reduction, including lipid modification. Dec 2023 [internet publication].Full text

Expert Dyslipidemia Panel of the International Atherosclerosis Society Panel members. An International Atherosclerosis Society position paper: global recommendations for the management of dyslipidemia - full report. J Clin Lipidol. 2014 Jan-Feb;8(1):29-60.Full text Abstract

Writing Committee; Lloyd-Jones DM, Morris PB, Ballantyne CM, et al. 2022 ACC Expert Consensus Decision Pathway on the role of nonstatin therapies for LDL-cholesterol lowering in the management of atherosclerotic cardiovascular disease risk: a report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol. 2022 Oct 4;80(14):1366-418.Full text Abstract

Cholesterol Treatment Trialists' (CTT) Collaboration; Fulcher J, O'Connell R, Voysey M, et al. Efficacy and safety of LDL-lowering therapy among men and women: meta-analysis of individual data from 174,000 participants in 27 randomised trials. Lancet. 2015 Apr 11;385(9976):1397-405. Abstract

Grundy SM, Cleeman JI, Mertz CN, et al; National Heart, Lung, and Blood Institute; American College of Cardiology Foundation; American Heart Association. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation. 2004 Jul 13;110(2):227-39.Full text Abstract

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials
- Obstructive liver disease
- Nephrotic syndrome
- Chronic renal insufficiency
More Differentials
Guidelines
- Cardiovascular disease: risk assessment and reduction, including lipid modification
- Consensus statement on homozygous familial hypercholesterolaemia: new treatments and clinical guidance
More Guidelines
Patient information
High cholesterol
High cholesterol: questions to ask your doctor
More Patient information
Calculators
Cardiovascular Risk Assessment in Men (10-year, patient information, Framingham 2008)
Cardiovascular Risk Assessment in Women (10-year, patient information, Framingham 2008)
More Calculators
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Hypercholesterolaemia

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Treatment algorithm

with clinical ASCVD: very high risk

with clinical ASCVD: not very high risk and age ≤75 years

with clinical ASCVD: not very high risk and age >75 years

without clinical ASCVD: LDL-C ≥4.9 mmol/L (≥190 mg/dL) without diabetes mellitus (age 20-75 years)

without clinical ASCVD: LDL-C ≥4.1 mmol/L (≥160 mg/dL) without diabetes mellitus (age 20-39 years)

without clinical ASCVD: LDL-C 1.8 to 4.9 mmol/L (70-189 mg/dL) without diabetes mellitus (age 40-75 years)

without clinical ASCVD: LDL-C 1.8 to 4.9 mmol/L (70-189 mg/dL) without diabetes mellitus (age >75 years)

without clinical ASCVD: with diabetes mellitus and risk enhancers (age 20-39 years)

without clinical ASCVD: with diabetes mellitus, 10-year ASCVD predicted risk <7.5% and no risk factors (age 40-75 years)

without clinical ASCVD: with diabetes mellitus, 10-year ASCVD predicted risk ≥7.5% and risk enhancers (age 40-75 years)

without clinical ASCVD: with diabetes mellitus (age >75 years)

familial hypercholesterolaemia

Contributors

Authors

Thorsten Leucker, MD, PhD

Disclosures

Richard A. Ferraro, MD

Disclosures

Acknowledgements

Disclosures

Peer reviewers

Mahi Lakshmi Ashwath, MD

Disclosures

Deepak Bhatnagar, TD MBBS PhD FRCP FRCPI FRCPath

Disclosures

References

Key articles

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials

Guidelines

Patient information

Calculators

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice