Hyperlipidemia
Hyperlipidaemia is elevated blood cholesterol or triglycerides — a silent but major risk factor for heart attack, stroke, and peripheral artery disease. Expert lipid management targets LDL reduction based on individual cardiovascular risk, using statins, ezetimibe, and PCSK9 inhibitors where needed.
A raw egg yolk presented simply on a white dish
Hyperlipidaemia refers to elevated levels of cholesterol and/or triglycerides in the blood — a major modifiable risk factor for coronary artery disease, stroke, peripheral artery disease, and aortic disease. Because it produces no symptoms, it is frequently undetected until a cardiovascular event occurs. Early identification, accurate cardiovascular risk stratification, and targeted treatment are essential to prevent serious outcomes.
Understanding Cholesterol
A standard fasting lipid panel measures total cholesterol, LDL (low-density lipoprotein), HDL (high-density lipoprotein), and triglycerides. LDL cholesterol is the primary driver of atherosclerotic plaque formation — it accumulates within arterial walls, narrows the lumen, and destabilises over time, triggering heart attack and stroke. HDL facilitates reverse cholesterol transport back to the liver and is cardioprotective. Elevated triglycerides contribute independently to cardiovascular and pancreatic risk. Non-HDL cholesterol — total cholesterol minus HDL — is an increasingly used composite marker that captures all atherogenic lipid particles.
LDL Targets by Cardiovascular Risk
Treatment targets are determined by overall cardiovascular risk, not cholesterol numbers alone. Current ESC guidelines recommend LDL below 1.8 mmol/L for high-risk patients — those with diabetes, hypertension, or significant risk factors — and below 1.4 mmol/L for very high-risk patients, including those with established coronary artery disease, peripheral artery disease, or prior stroke. For patients with recurrent cardiovascular events despite treatment, an LDL target below 1.0 mmol/L is recommended. Cardiovascular risk is calculated using validated tools including the Framingham Risk Score and SCORE2.
Causes & Risk Factors
Hyperlipidaemia results from a combination of dietary, lifestyle, and genetic factors. Diets high in saturated and trans fats, physical inactivity, obesity, smoking, type 2 diabetes, and hypothyroidism all contribute to adverse lipid profiles. Familial hypercholesterolaemia (FH) is an inherited condition causing severely elevated LDL — often above 5–6 mmol/L — from birth, conferring very high lifetime cardiovascular risk if untreated. FH affects approximately 1 in 250 people and is significantly underdiagnosed; a cardiologist should be involved in management to ensure appropriate treatment intensity and family cascade screening.
Treatment
- Lifestyle modification — reduced saturated fat intake, increased aerobic exercise, weight optimisation, and smoking cessation — lowers LDL by 10–20% and is recommended for all patients regardless of medication need.
- Statins remain the cornerstone of pharmacological lipid management, reducing LDL by 30–55% depending on agent and dose, with robust evidence for cardiovascular event reduction across all risk categories.
- Ezetimibe inhibits intestinal cholesterol absorption and provides an additional LDL reduction of approximately 15–20% when combined with a statin — a well-tolerated and cost-effective addition.
- PCSK9 inhibitors (evolocumab, alirocumab) are injectable monoclonal antibodies that dramatically reduce LDL by 50–60% on top of maximally tolerated statin therapy. They are indicated for very high-risk patients, those with FH, or patients with statin intolerance who cannot achieve target LDL with oral agents alone.
- Inclisiran is a newer injectable RNA-interference therapy administered twice yearly, offering sustained LDL reduction with minimal burden — an emerging option for long-term lipid management.
- Icosapent ethyl (EPA) and fibrates are used for significant hypertriglyceridaemia, particularly when triglycerides exceed 5.6 mmol/L and pancreatitis risk is elevated.
Monitoring & Long-Term Care
Lipid levels should be reassessed 8–12 weeks after initiating or adjusting therapy to confirm target attainment. Once stable, annual monitoring is appropriate. Liver enzymes and creatine kinase are checked at baseline and when symptoms suggest statin-related side effects. Long-term specialist follow-up ensures lipid targets are maintained as cardiovascular risk evolves and new therapies become available.
Elevated cholesterol, a family history of heart disease, or concerned about cardiovascular risk? Dr. Peter Chang consults at Paragon Medical Centre, Orchard Road. Book a lipid assessment today.