Cholesterol

What is cholesterol?

Cholesterol is a fatty substance that occurs naturally in the body. It performs several vital functions. It is needed to make the membranes surrounding the body's cells, and is the basic material that is converted to certain hormones. Your body makes all the cholesterol you need. You need only a small amount of fat in your diet to make enough cholesterol to stay healthy.

The fat and cholesterol you eat are absorbed in the intestine and transported to the liver. The liver converts fat into cholesterol, and releases cholesterol into the bloodstream. There are two main types of cholesterol: low-density lipoprotein (LDL) cholesterol (the "bad" cholesterol) and high-density lipoprotein (HDL) cholesterol (the "good" cholesterol).

High levels of LDL cholesterol are linked to atherosclerosis, which is the accumulation of cholesterol-rich fatty deposits in arteries. This can cause arteries to narrow or become blocked, slowing or stopping the flow of blood to vital organs, especially the heart and brain. Atherosclerosis affecting the heart is called coronary artery disease, and it can set the stage for a heart attack. When atherosclerosis blocks arteries that supply blood to the brain, it can cause a stroke.

People with high levels of HDL cholesterol are less likely to develop cardiovascular disease. However, if a person has both a high HDL and high LDL cholesterol level, he or she might still need treatment to lower the LDL level.

The target level for LDL cholesterol depends on whether or not a person already has a disease caused by atherosclerosis, or diabetes, or other risk factors for coronary artery disease. In addition to a high LDL cholesterol level and diabetes, risk factors for coronary artery disease include:

• being a male older than 45
• being a female older than 55
• being a female with premature menopause
• having a family history of premature coronary artery disease (a father or brother younger than 55 with coronary artery disease, or a mother or sister younger than 65 with coronary artery disease)
• smoking cigarettes
• having high blood pressure
• not having enough HDL cholesterol.

What is a normal cholesterol level?

A simple blood test, called a lipid panel, is used to measure total cholesterol, LDL cholesterol, HDL cholesterol, and triglyceride levels.

Total blood cholesterol is determined by LDL and HDL values, as well as triglyceride levels. Your doctor will consider your overall heart disease risk when discussing your target cholesterol levels.

The ideal LDL cholesterol level is less than 70 milligrams per deciliter (mg/dL). If you have coronary artery disease, peripheral arterial disease, or have had an ischemic stroke, this should be your goal. If you have certain risk factors, your doctor may recommend an even stricter goal below 55 mg/dL.

If you do not have cardiovascular disease or risk factors for it, an LDL cholesterol level of 100 to 130 mg/dL may be acceptable.

Your HDL cholesterol level also matters. People with levels below 40 mg/dL are more likely to develop atherosclerosis, heart disease, and stroke.

In general, a triglyceride level of under 150 mg/dL is a good goal.

Does a high cholesterol level cause symptoms?

Most people with high cholesterol don't have any symptoms until cholesterol-related atherosclerosis causes significant narrowing of the arteries leading to their hearts or brains. The result can be heart-related chest pain (angina) or other symptoms of coronary artery disease, as well as symptoms of decreased blood supply to the brain (transient ischemic attacks or stroke).

About one out of every 500 people has an inherited disorder called familial hypercholesterolemia, which can cause extremely high cholesterol levels (above 300 milligrams per deciliter). People with this disorder can develop nodules filled with cholesterol (xanthomas) over various tendons, especially the Achilles tendons of the lower leg. Cholesterol deposits also can occur on the eyelids, where they are called xanthelasmas.

What's the best diet to lower cholesterol?

There is no consensus on the best diet to lower total and LDL cholesterol.

One heart-healthy eating pattern is the Mediterranean-style diet. This diet is characterized by:

• getting the majority of daily food calories from plant sources, especially fruits and vegetables, grains, beans, nuts, and seeds
• using olive oil as the principal fat, replacing other fats and oils
• having some low-fat cheese and/or yogurt daily
• eating fish at least a couple of times per week
• limiting processed foods
• no more than two alcoholic drinks per day for men and no more than one per day for women.

To maintain a desirable weight, you should take in only as many calories as you burn each day. If you need to lose weight, you need to consume fewer calories than you burn.

People who aren't sure how to follow such a diet may find it useful to work with a health care professional such as a dietitian, nutritionist, doctor, or nurse.

In addition to dietary changes, you should get at least 30 minutes of moderate-intensity exercise, such as brisk walking, daily.

What's the best drug treatment for high cholesterol?

Whether you need medication to lower your cholesterol level depends on how you respond to diet and your personal risk of heart attack and stroke.

There are five types of cholesterol-lowering medications. A statin drug is almost always tried first.

Statins are also called HMG-CoA reductase inhibitors. They include lovastatin (Mevacor), simvastatin (Zocor), pravastatin (Pravachol), fluvastatin (Lescol), atorvastatin (Lipitor), and rosuvastatin (Crestor).

Statins block an enzyme called HMG-CoA reductase, which is necessary for the production of cholesterol.

Statins do much more than lower your LDL cholesterol. They lower your risk of developing hardening of the arteries (atherosclerosis), and reduce the risk of having a heart attack or stroke. Statins also have a protective anti-inflammatory effect.

When a person taking a statin does not reach their goal cholesterol level, doctors sometimes add ezetimibe. Ezetimibe (Zetia) inhibits absorption of cholesterol from the intestine. Ezetimibe combined with the statin drug simvastatin is sold under the brand name Vytorin.

Cholesterol-lowering therapies called PCSK9 inhibitors are more potent than statins. PCSK9 inhibitors are most useful for people with familial hypercholesterolemia, who have extremely high cholesterol levels.

People with coronary artery disease who either don’t reach goal with a high-dose statin drug, or cannot tolerate statins because of side effects, may also be candidates for this therapy.

PCSK9 inhibitors are much more expensive than most statins. Most must be injected. The first pill version of a PCSK9 inhibitor, enlicitide (Lipfendra), was released in July 2026.

Medications are also available to lower high triglyceride levels. The most common types of drugs prescribed for people with high triglyceride levels are:

• fibrates, including gemfibrozil (Lopid), fenofibrate (Tricor), and clofibrate (Abitrate)
• omega-3 fatty acids: omega-3 fatty acid ethyl esters (Lovaza) for people with very high triglyceride levels. People with even moderately elevated triglyceride levels and increased risk of cardiovascular disease may benefit from icosapent ethyl (Vascepa).