People who have already had triglyceride-related pancreatitis may be treated at lower levels. In these situations, a class of medication called fibrates are usually the first line of treatment. People with diabetes — People with diabetes type 1 or 2 are at high risk of heart disease.

A moderate- or high-intensity statin is recommended in most adults with diabetes, regardless of their baseline LDL cholesterol level. See "Patient education: Type 2 diabetes: Overview Beyond the Basics ". Older adults — The decision to treat high cholesterol levels in a person over the age of 75 depends upon the individual's "chronologic age" age in years as well as their "physiologic age" which takes into account their health and fitness level.

A person with a limited life span and underlying illness may not need to receive drug therapy. On the other hand, an otherwise healthy older adult should not be denied drug therapy simply on the basis of age alone.

In general, the treatment goals discussed above apply for people of all ages. These patients often have a genetic factor that leads to a change in how cholesterol is processed in the body, and they have high levels of cholesterol from birth.

As such, their risk of developing heart disease is much higher. These patients are recommended for treatment regardless of the risk score, with treatment often started in late teenage years. You can help lower your lipid levels with lifestyle changes, medications, or a combination of both.

In certain cases, a health care provider will recommend a trial of lifestyle changes before recommending a medication. The best approach for you will depend on your individual situation, including your lipid levels, health conditions, risk factors, medications, and lifestyle.

Lifestyle changes — If you have high low-density lipoprotein LDL cholesterol, you should try to make some changes in your day-to-day habits, including reducing the amount of total and saturated fat in your diet, losing weight if you are overweight or obese , getting regular aerobic exercise, and eating plenty of fruits and vegetables see "Patient education: Exercise Beyond the Basics " and "Patient education: Diet and health Beyond the Basics ".

A plant-based diet is an effective strategy to lowering LDL cholesterol. The benefits of these lifestyle changes usually become evident within 6 to 12 months. However, the success of lipid lowering with lifestyle modification varies widely, and health care providers sometimes recommend beginning medication sooner.

Medications — There are many medications available to help lower elevated levels of LDL cholesterol. Each category of medication varies in how it works, how effective it is, and how much it costs. Your health care provider will recommend a medication or combination of medications based on your blood lipid levels and other individual factors.

Statins — Statins are one of the best-studied classes of medications and the most commonly used drugs for lowering LDL cholesterol.

They are the most effective drugs for prevention of coronary heart disease, heart attack, stroke, and death. Available statins include atorvastatin former brand name: Lipitor , rosuvastatin former brand name: Crestor , and several other similar medications table 1.

Statins decrease the body's production of cholesterol and increase removal of cholesterol by the liver, so they reduce LDL cholesterol levels by as much as 25 to 55 percent.

In addition, they can lower triglycerides. Statins may also reduce inflammation and may prevent heart attacks and strokes through this mechanism. While most people tolerate statins well, there are some potential side effects, mainly muscle pain, aches, or weakness.

Use of statins may also increase the risk of developing diabetes, although the risk is seen mostly in those with prediabetes, and the benefit in reduction on heart attack and stroke is about four times that of the risk of developing diabetes. Changing statins and using low doses often can avoid these issues, but if not, non-statin medications can be used to lower LDL cholesterol.

It is important to closely follow the dosing instructions for when to take statins; some are more effective when taken before bedtime while others should be taken with a meal.

In addition, some foods, such as grapefruit or grapefruit juice, can increase the risk of side effects of statins. Most manufacturers recommend that people who take lovastatin, simvastatin, or atorvastatin consume no more than one-half of a grapefruit or 8 ounces of grapefruit juice per day. Ezetimibe — Ezetimibe brand name: Zetia blocks the body's ability to actively transport cholesterol from food as well as cholesterol that the body produces internally.

It lowers LDL cholesterol levels by 20 to 25 percent and has relatively few side effects. It is usually prescribed in combination with a statin but is also used alone in patients who cannot tolerate a statin.

When used in combination with a statin after an acute coronary syndrome eg, heart attack , ezetimibe provides a small additional reduction in the risk of having another cardiovascular event.

PCSK9 inhibitors — PCSK9 monoclonal antibody inhibitors are another class of drugs that lower LDL cholesterol levels sample brand names: Praluent, Repatha table 1 ; they are given by injection under the skin every two to four weeks.

They reduce cardiovascular events such as heart attack or stroke and potentially death. Aside from mild skin reactions at the site of injection, they have few side effects.

Inclisiran brand name Leqvio is a PCSK9 inhibitor that is given by injection once, 90 days later, and then every six months. However, they are expensive and their use is limited to patients treated with maximal tolerated statins who have persistent elevations of LDL cholesterol.

Bile acid sequestrants — The bile acid sequestrants include colesevelam brand name: Welchol , colestipol brand name: Colestid , and cholestyramine sample brand names: Prevalite, Questran table 1. These medications bind to bile acids in the intestine, reducing the amount of cholesterol the body absorbs from foods.

They are used only occasionally. They lower LDL cholesterol only modestly 10 to 15 percent. Side effects can be bothersome and may include nausea, bloating, cramping, and liver damage. Taking psyllium a fiber supplement, such as Metamucil can sometimes reduce the dose required and the side effects.

Bile acid sequestrants can interact with some medications, including as digoxin brand name: Lanoxin and warfarin brand name: Jantoven , and with the absorption of fat-soluble vitamins including vitamins A, D, K, and E.

Taking these medications at different times of day can solve these problems in some cases. Bempedoic acid — Bempedoic acid brand name: Nexletol is the newest lipid-lowering agent, and it is approved for lowering LDL cholesterol. It works by inhibiting cholesterol synthesis at a step before the HMG-CoA reductase or the enzyme inhibited by statin therapy.

Bempedoic acid alone or in combination with a statin or ezetimibe brand name: Nexlizet lowers LDL cholesterol as well as other atherogenic proteins. Bempedoic acid can reduce the risk of cardiovascular events such as heart attacks.

Side effects include an increase in the incidence of gout, gallstones, kidney damage, and small increases in liver enzymes.

Early studies reported Achilles tendon rupture as a rare side effect; however, this effect was not seen in a recent large trial. Omega-3 — Oily fish, such as mackerel, herring, bluefish, sardines, salmon, and anchovies, contain two important fatty acids called docosahexaenoic acid DHA and eicosapentaenoic acid EPA.

Eating a diet that includes one to two servings of oily fish per week can lower triglyceride levels and reduce the risk of death from coronary heart disease. Fish oil supplements, supplements with low-dose mixed fish oils usually approximately 1 gram per day of combined DHA and EPA , had been thought to provide cardiac benefit, but large trials have found no significant benefit.

As such, they are no longer recommended. A second study of a high-dose agent that had both EPA and DHA failed to provide benefit, suggesting that the EPA only preparation at the 4 g dose is important. However, the trials found that omega-3 fatty acid medications increase the risk of atrial fibrillation.

Therefore, a discussion with your cardiologist on the net benefit or harm from taking fish oil supplements including icosapent ethyl is needed before starting this treatment. Nicotinic acid niacin — Nicotinic acid is a vitamin that is available in immediate-release, sustained-release, and extended-release formulations table 1.

Nicotinic acid is rarely used for a high cholesterol. In most situations, ezetimibe or a PCSK9 inhibitor is tried before nicotinic acid. Historically, this agent used to be used to raise HDL cholesterol levels, but that is no longer recommended.

It is sometimes used for patients with high lipoprotein a levels and LDL cholesterol that is refractory to more effective and better-tolerated medications statins, ezetimibe and PCSK9 inhibitors.

Nicotinic acid is associated with many side effects, including flushing when the face or body turns red and becomes warm , itching, nausea, numbness and tingling, and worsening of gout.

This medication can also cause liver damage; people who use it require regular blood tests to monitor their liver function. Red yeast rice — Red yeast rice is a fermented rice product that can lower serum cholesterol. Red yeast rice contains naturally occurring substances called monacolins that act to reduce cholesterol by a mechanism similar to that of statins.

Although red yeast rice is effective for lowering total and LDL cholesterol, there is not evidence that it decreases rates of cardiovascular events or that it is safe to take long-term. Moreover, red yeast rice supplements are not standardized in the United States.

Different commercial preparations vary widely in the amount of the active ingredient, and some commercial preparations have been shown to contain potentially toxic substances or lovastatin, a statin medication. Soy protein — Soy protein contains isoflavones, which mimic the action of estrogen.

A diet high in soy protein can slightly lower levels of total cholesterol, LDL cholesterol, and triglycerides and raise levels of high-density lipoprotein HDL cholesterol. However, normal protein should not be replaced with soy protein or isoflavone supplements in an effort to lower cholesterol levels.

Soy foods and food products eg, tofu, soy butter, edamame, some soy burgers are likely to have beneficial effects on lipids and cardiovascular health because they are low in saturated fats and high in unsaturated fats.

Garlic — Garlic has not been proven to be effective in lowering cholesterol. Plant stanols and sterols — Plant stanols and sterols may act by blocking the absorption of cholesterol in the intestine. They are naturally found in some fruits, vegetables, vegetable oils, nuts, seeds, and legumes.

They are also available in commercially prepared products such as margarine Promise Active and Benecol , orange juice Minute Maid Premium Heart Wise , and rice milk Rice Dream Heart Wise as well as dietary supplements Benecol SoftGels and Cholest-Off.

Despite lowering cholesterol levels, there are no studies demonstrating a reduced risk of coronary heart disease in people who consume supplemental plant stanols and sterols. These products need to be studied more before they can be recommended. Although medications can rapidly lower your levels within a week , it often takes 6 to 12 months before the effects of lifestyle modifications are noticeable.

Once you have an effective treatment plan and you begin to see results, it is important to stay committed to the plan. Stopping treatment usually allows lipid levels to rise again and increases your risk for heart attack, stroke, or other cardiovascular problems.

Even while taking medications, maintaining a healthy lifestyle is crucial to obtain the most benefit from these therapies. Most people who stop treatment do so because of perceived side effects.

However, there are a wide variety of medications available today, which should make it possible for most people to find an option that works for them.

Talk with your health care provider if a specific medication is not working for you; he or she can recommend alternatives that are compatible with your lifestyle and preferences.

Your healthcare provider is the best source of information for questions and concerns related to your medical problem. This article will be updated as needed on our web site www.

Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials. Treatment protocols and decision aids can assist clinical teams and their patients in making informed decisions that can lead to fewer heart attacks and strokes.

For people with high LDL cholesterol levels or for others at high risk for having an ASCVD event in the next 10 years, experts recommend lifestyle changes and cholesterol-lowering medications to lower ASCVD risk.

Clinical blood cholesterol treatment guidelines released in from the American College of Cardiology ACC and the American Heart Association AHA recommended statins for four main groups who might benefit. In November , new clinical guidelines were released by the ACC, AHA, and others that provide additional specificity to the recommendations, reinforce the need for appropriate-intensity statin therapy among people at risk of having an ASCVD event, and emphasize the importance of patient—clinician shared decision making.

View the cholesterol management guidelines. Cholesterol is a waxy, fatlike substance. It is produced by the liver and is present in dietary sources. It is a major component of cell membranes and is used to make hormones, vitamin D, and bile acids used in digestion.

Cholesterol is carried through the blood on lipoproteins. There are two major types of lipoproteins:. Excess LDL cholesterol is deposited in the walls of arteries throughout the body. This can lead to ASCVD, which includes heart attack, stroke, transient ischemic attack TIA , stable or unstable angina, and peripheral artery disease PAD , including aortic aneurysm, all of atherosclerotic origin.

As many as 1 in U. adults may have a genetic condition called familial hypercholesterolemia FH , an inherited disorder that causes the liver to have problems metabolizing and removing excess LDL cholesterol, resulting in very high LDL levels.

Recommended treatment for FH includes healthy lifestyle choices and statin therapy, started early and continued with close follow-up to reach treatment goals. Data from — indicate that only about half adults over age 21 who might benefit from statin use are taking them.

Some groups are more likely to use statins for cholesterol management than others:. The Skip directly to site content Skip directly to search.

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View Transcript. References Stone NJ, Robinson JG, Lichtenstein AH, Bairey Merz CN, Blum CB, Eckel RH, et al. J Am Coll Cardiol. Grundy SM, Stone NJ, Bailey AL, Beam C, Birtcher KK, Blumenthal RS, et al.

Bucholz EM, Rodday AM, Kolor K, Khoury MJ, de Ferranti SD. Prevalence and predictors of cholesterol screening, awareness, and statin treatment among US adults with familial hypercholesterolemia or other forms of severe dyslipidemia — Nordestgaard BG, Chapman MJ, Humphries SE, Ginsberg HN, Masana L, Descamps OS, et al.

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Aspirin or Anticoagulant Use Blood Pressure Control Cholesterol Management Smoking Cessation Cardiac Rehabilitation. Self-Measured Blood Pressure SMBP Monitoring Hypertensive Disorders of Pregnancy Medication Adherence Health IT Municipalities Tool Kit.

Data Fact Sheets ABCS of Heart Health Cardiac Rehabilitation At A Glance Improving Medication Adherence Among Patients with Hypertension. Section Navigation. Facebook Twitter LinkedIn Syndicate. Cholesterol Management. Minus Related Pages. On This Page. Featured Resource About Cholesterol About Statins Tools and Resources References.

About Cholesterol. How do statins prevent heart attacks and strokes? View Transcript. References Stone NJ, Robinson JG, Lichtenstein AH, Bairey Merz CN, Blum CB, Eckel RH, et al.

J Am Coll Cardiol. Grundy SM, Stone NJ, Bailey AL, Beam C, Birtcher KK, Blumenthal RS, et al. Bucholz EM, Rodday AM, Kolor K, Khoury MJ, de Ferranti SD. Prevalence and predictors of cholesterol screening, awareness, and statin treatment among US adults with familial hypercholesterolemia or other forms of severe dyslipidemia — Nordestgaard BG, Chapman MJ, Humphries SE, Ginsberg HN, Masana L, Descamps OS, et al.

Familial hypercholesterolaemia is underdiagnosed and undertreated in the general population: guidance for clinicians to prevent coronary heart disease: consensus statement of the European Atherosclerosis Society.

Eur Heart J. Reducing the burden of disease and death from familial hypercholesterolemia: A call to action. Am Heart J. Cholesterol-lowering medicine. Updated October 31, Please read the Disclaimer at the end of this page.

A high cholesterol level also called "hypercholesterolemia" can significantly increase your risk of developing chest pain, heart attack, and stroke.

Fortunately, a number of effective treatment options are available. While total cholesterol has been a primary focus in the past, current guidelines focus on low-density lipoprotein LDL cholesterol. Higher levels of LDL cholesterol are associated with greater risk of heart attack, stroke, need for stenting or coronary bypass surgery, and death.

Studies over the past 50 years have shown that lowering LDL cholesterol leads to lower rates of these cardiac events. A second type of cholesterol, triglycerides, also has been associated with increased risk. Conversely, high-density lipoprotein HDL cholesterol is associated with lower risk, although studies have suggested that changing HDL is not a way to change risk.

Cholesterol levels notably LDL cholesterol and triglycerides can almost always be lowered with a combination of weight loss achieved with diet and exercise , and medications.

As your level decreases, so does your risk of developing cardiovascular disease CVD , including disease of the blood vessels supplying the heart coronary artery disease , brain cerebrovascular disease , and limbs peripheral vascular disease.

This results in a decrease in your risk of having a heart attack or stroke. Even if you already have established CVD, it's not too late to lower your risk. A full explanation of what cholesterol is, how it affects your health, and when a level should be measured is available separately see "Patient education: High cholesterol and lipids Beyond the Basics ".

This topic will discuss when treatment is recommended, the available treatment options, and the risks, benefits, and effectiveness of each approach.

The decision to start cholesterol-lowering treatment is made on a case-by-case basis. Health care providers consider current lipid levels, your risk of developing a cardiac event, the presence or absence of cardiovascular disease CVD , and other risk factors.

People with CVD — Studies have shown that in people with coronary heart disease, taking medication to significantly lower the level of "bad" cholesterol, called low-density lipoprotein LDL cholesterol, is beneficial.

Many health care providers recommend treating anyone with CVD including people who have coronary heart disease or have had a stroke with high-dose statin therapy see 'Statins' below. People who have been hospitalized following a heart attack also called a "myocardial infarction" or MI or after a coronary intervention procedure eg, stent placement or bypass surgery are started on cholesterol-lowering medication usually a high-dose statin before going home from the hospital; they are also advised to make lifestyle changes related to improving their diet and exercise habits, reduce their weight if overweight, regardless of their LDL cholesterol level.

See "Patient education: Heart attack recovery Beyond the Basics ". If you have CVD, your health care provider can talk to you about the different ways to manage your cholesterol and which approach is best for your situation.

Some patients cannot tolerate statins, but there are several other classes of drugs that can lower LDL cholesterol. People without CVD — People without a history of CVD also benefit from cholesterol-lowering therapy, although the goal is generally not as aggressive as in people with CVD.

The decision of whether to start treatment is based on your individual risk for developing heart disease.

Calculators are available that can estimate this risk based on your age, sex, medical history, and other characteristics see "Patient education: High cholesterol and lipids Beyond the Basics ", section on 'Calculating your risk of cardiovascular disease'.

Some clinicians recommend treatment at a particular level of risk such as a 7. Sometimes a calcium score test is done to see if plaque is present in the heart arteries; if so, then treatment is recommended.

As with people who already have known CVD, when the decision is made to start medication, the first choice is usually a statin. See 'Statins' below. People with high triglyceride levels — Triglycerides, like cholesterol, are a type of lipid. High triglycerides called "hypertriglyceridemia" are also associated with an increased risk of heart disease.

These need to be assessed on a fasting blood test because eating any food prior to the test will increase the levels. Dietary interventions and exercise are usually effective in lowering triglycerides. The dietary interventions include limiting intake of refined carbohydrates, excess calories, and alcohol.

For reducing cardiovascular risk, the first step is to reduce the LDL to below the target level see 'Statins' below and then check the fasting triglyceride level. See 'Omega-3' below.

People who have already had triglyceride-related pancreatitis may be treated at lower levels. In these situations, a class of medication called fibrates are usually the first line of treatment. People with diabetes — People with diabetes type 1 or 2 are at high risk of heart disease.

A moderate- or high-intensity statin is recommended in most adults with diabetes, regardless of their baseline LDL cholesterol level. See "Patient education: Type 2 diabetes: Overview Beyond the Basics ". Older adults — The decision to treat high cholesterol levels in a person over the age of 75 depends upon the individual's "chronologic age" age in years as well as their "physiologic age" which takes into account their health and fitness level.

A person with a limited life span and underlying illness may not need to receive drug therapy. On the other hand, an otherwise healthy older adult should not be denied drug therapy simply on the basis of age alone.

In general, the treatment goals discussed above apply for people of all ages. These patients often have a genetic factor that leads to a change in how cholesterol is processed in the body, and they have high levels of cholesterol from birth. As such, their risk of developing heart disease is much higher.

These patients are recommended for treatment regardless of the risk score, with treatment often started in late teenage years. You can help lower your lipid levels with lifestyle changes, medications, or a combination of both. In certain cases, a health care provider will recommend a trial of lifestyle changes before recommending a medication.

The best approach for you will depend on your individual situation, including your lipid levels, health conditions, risk factors, medications, and lifestyle.

Lifestyle changes — If you have high low-density lipoprotein LDL cholesterol, you should try to make some changes in your day-to-day habits, including reducing the amount of total and saturated fat in your diet, losing weight if you are overweight or obese , getting regular aerobic exercise, and eating plenty of fruits and vegetables see "Patient education: Exercise Beyond the Basics " and "Patient education: Diet and health Beyond the Basics ".

A plant-based diet is an effective strategy to lowering LDL cholesterol. The benefits of these lifestyle changes usually become evident within 6 to 12 months. However, the success of lipid lowering with lifestyle modification varies widely, and health care providers sometimes recommend beginning medication sooner.

Medications — There are many medications available to help lower elevated levels of LDL cholesterol. Each category of medication varies in how it works, how effective it is, and how much it costs. Your health care provider will recommend a medication or combination of medications based on your blood lipid levels and other individual factors.

Statins — Statins are one of the best-studied classes of medications and the most commonly used drugs for lowering LDL cholesterol. They are the most effective drugs for prevention of coronary heart disease, heart attack, stroke, and death. Available statins include atorvastatin former brand name: Lipitor , rosuvastatin former brand name: Crestor , and several other similar medications table 1.

Statins decrease the body's production of cholesterol and increase removal of cholesterol by the liver, so they reduce LDL cholesterol levels by as much as 25 to 55 percent. In addition, they can lower triglycerides. Statins may also reduce inflammation and may prevent heart attacks and strokes through this mechanism.

While most people tolerate statins well, there are some potential side effects, mainly muscle pain, aches, or weakness.