Managing high cholesterol

What cholesterol is and why it matters

Cholesterol is a fat-like substance the body produces and absorbs from food. Low-density lipoprotein (LDL) cholesterol contributes to atherosclerosis (fatty deposits in arteries), the main mechanism of vascular disease. High-density lipoprotein (HDL) carries cholesterol away from the arteries and is protective. Triglycerides are another type of blood fat.

Mid-life cholesterol levels predict dementia risk decades later. Lifelong high LDL is associated with higher dementia incidence; reducing LDL with statins reduces cardiovascular events and probably dementia risk too.

UK targets

NICE CG181 uses cardiovascular risk assessment rather than fixed cholesterol thresholds. A QRISK3 calculator estimates 10-year cardiovascular risk based on age, sex, ethnicity, blood pressure, cholesterol, smoking, family history, BMI and several other factors.

General reference ranges:

• Total cholesterol: under 5.0 mmol/L;
• LDL cholesterol: under 3.0 mmol/L;
• HDL cholesterol: above 1.0 (men) or 1.2 (women) mmol/L;
• Triglycerides: under 1.7 mmol/L;
• Total cholesterol to HDL ratio: under 4.5.

For people with established cardiovascular disease, tighter targets apply (LDL under 1.8 mmol/L is common).

Lifestyle measures

• Reduce saturated fat (under 11% of total calories);
• Increase soluble fibre (oats, beans, lentils, fruit);
• Two to three portions of oily fish a week (salmon, mackerel, sardines, trout);
• Plant-based proteins (lentils, beans, soy);
• Nuts (a handful a day);
• Olive oil as the main fat (Mediterranean Diet);
• Reduce trans fats (largely already removed from UK food supply);
• Weight management;
• Exercise: 150 minutes of moderate activity weekly.

Statins

Statins are the first-line cholesterol-lowering medication class. Common UK statins:

• Atorvastatin (20 mg, 40 mg, 80 mg): widely used, well tolerated;
• Simvastatin (20 mg, 40 mg): older option;
• Rosuvastatin (5 mg, 10 mg, 20 mg): potent, may suit when Atorvastatin not tolerated.

Side effects:

• Muscle aches (most common; usually mild);
• Mild liver enzyme rise (usually subclinical);
• Small increase in diabetes risk (outweighed by cardiovascular benefit);
• Very rarely, severe muscle injury (rhabdomyolysis).

For most people, statin benefits substantially outweigh risks. Newer non-statin agents (Ezetimibe, PCSK9 inhibitors, Bempedoic Acid) are options when statins are not tolerated.

For people with dementia

Statin treatment is generally continued in established dementia, particularly mixed and Vascular subtypes. Considerations:

• Polypharmacy and adherence challenges;
• Time horizon: the cardiovascular benefit accrues over years;
• Quality of life and individual preferences.

Most older adults with dementia and an established vascular risk benefit from continued statin treatment.