Which is the bad cholesterol

Too high a cholesterol means that your blood values ​​for LDL and / or total cholesterol are suspicious because they exceed the average guideline values ​​for cholesterol. This indicates an increased risk of hardening of the arteries (arteriosclerosis) and its secondary diseases and should therefore be treated by a doctor.

How high the LDL cholesterol (LDL-C) can be in your case depends on the so-called overall cardiovascular risk (CV risk). Basically, the more risk factors there are for the development of cardiovascular diseases, the lower the LDL cholesterol levels should be.

LDL cholesterol is known as the “bad cholesterol”, as increased LDL values ​​can lead to vascular calcification with dangerous consequences. But the triglycerides also have an unfavorable influence on the blood vessels.

The antagonist HDL - the so-called "good cholesterol" - has positive effects on the blood vessels and the cholesterol level. Unfortunately, a high HDL value can only compensate a high LDL cholesterol value to a limited extent, so that today the therapy goals are mainly based on the LDL values. The attending physician must individually assess which cholesterol levels are considered normal and which are high-risk, depending on the risk factors and the results of the individual health check.

Patients should seek advice from cholesterol experts

High cholesterol levels increase the risk of heart attacks and strokes, but high cholesterol affects everyone differently. On the one hand there are people who have noticeably calcified blood vessels with only slightly elevated cholesterol levels, on the other hand there are also people who have only slight arteriosclerosis despite a very high cholesterol level.

With a measurement of the intima media thickness (IMD) of the carotid arteries using Doppler sonography, z. B. the cardiovascular risk can be better assessed. As part of a cardiovascular check, the elasticity of the veins can also be determined by measuring the pulse wave speed and the augmentation index. The measurement of the central (“aortic”) blood pressure is also important for estimating the risk, as this corresponds better to the actual blood pressure in the vessels than the blood pressure measured on the upper arm. In order to be able to assess the individual risk, an ultrasound examination of the abdominal aorta, a stress ECG, a stress echocardioraphy and a color Doppler ultrasound of the neck and leg vessels should be carried out to show any deposits (plaques). In borderline cases, we arrange for a cardiac CT scan with calcium scoring of the coronary arteries to be carried out by a cooperation partner to make a decision.

In addition, there are extensive laboratory determinations of special values ​​such as apolipoprotein B and non-HDL cholesterol, by means of which the risk of heart attack and stroke can be assessed even more precisely. Total apolipoprotein B, which is important for risk assessment, is underestimated in around 20% of patients simply by measuring LDL cholesterol. This is particularly common in patients with high triglycerides, diabetes mellitus, obesity or very low LDL. In these cases, apolipoprotein B and non-HDL cholesterol should also be determined.

The examinations of the cardiovascular check are carried out by private health insurance companies and aid agencies, as they follow the guidelines and recommendations of the European Society of Cardiology (ESC) and the European Artherosclerosis Society (EAS).

High cholesterol affects everyone differently. It is not uncommon for patients to have good blood vessels despite high cholesterol levels. On the other hand, there are also people in whom an only slightly increased cholesterol level has led to severe calcifications. The decision for or against medication must therefore be made dependent on the individual risk and not solely on the level of the cholesterol level.

The experts in our special cholesterol consultation will be happy to advise you personally.

The current recommendation of the European Society of Cardiology (ESC) and the European Atherosclerosis Society (EAS) can be viewed here.

Healthy, low risk people

A low risk is when the risk of having a heart attack or stroke in the next 10 years is less than 1%. The risk can be calculated with a SCORE (Systematic Coronary Risk Estimation). The most popular score systems are the ESC-SCORE and the PROCAM-SCORE (Prospective Cardiovascular Munster Study).

However, the SCORE systems do not take into account some factors and diseases that should be included in the risk assessment:

  • physical activity
  • psychosocial stress
  • Atrial fibrillation
  • Sleep apnea syndrome
  • Heart wall thickening
  • Kidney disease
  • Mental illnesses like depression
  • Autoimmune diseases such as Hashimoto's thyroiditis

The following guidelines apply to healthy people at low risk:

  • Total cholesterol <190 mg / dl = 5.0 mmol / l
  • LDL <116 mg / dl = 3.0 mmol / l
  • HDL at least 40 mg / dl (men) or 48 mg / dl (women)
  • Triglycerides <150 mg / dl = 1.69 mmol / l

Medium risk people

A medium risk is present in patients who have a 10-year risk of 1 to 5% for a heart attack or stroke when the risk profile is determined.

With a medium risk, the following guide values ​​apply:

  • Total cholesterol <190 mg / dl = 5 mmol / l
  • LDL <100 mg / dl = 2.6 mmol / l
  • HDL at least 40 mg / dl (men) or 48 mg / dl (women)
  • Apolipoprotein A1> 120 mg / dl (women> 140 mg / dl)
  • Triglycerides <150 mg / dl = 1.69 mmol / l
  • Non-HDL cholesterol <130 mg / dl
  • Apolipoprotein B <100 mg / dl

High risk people

If you are at high risk, your LDL cholesterol should be lowered to below 70 mg / dl (1.8 mmol / l). A high risk is when the risk of having a heart attack or stroke in the next 10 years is 5 to 10%.

This group also includes people with congenital elevated familial cholesterol, diabetes mellitus (without end organ damage or other cardiovascular risk factors), patients with moderate kidney weakness (GFR 30–59), smokers, people with severe hypertension (more than 180/110), severe elevated triglycerides (over 310 mg / dL) or low HDL levels. If parents or siblings have had a heart attack or stroke under the age of 60, they are also considered to be at high risk.

In patients at high risk, the LDL cholesterol value should be lowered below 70 mg / dl. If the LDL was increased by 100–200 mg / dl prior to the cholesterol-lowering therapy, a lowering of the LDL by more than 50% is recommended. So should z. B. then an LDL value of 160 mg / dl can be reduced to at least 80 mg / dl.

If there is a high risk, the following guidelines apply:

  • Total cholesterol <190 mg / dl = 5 mmol / l
  • LDL <70mg / dl = 1.8 mmol / l (or reduction by 50%)
  • HDL at least 40 mg / dl (women: 48 mg / dl)
  • Apolipoprotein A1> 120 mg / dl (women> 140 mg / dl)
  • Triglycerides <150 mg / dl = 1.69 mmol / l
  • Non-HDL cholesterol <100 mg / dl
  • Apolipoprotein B <80 mg / dl

People at very high risk

Even lower target values ​​are aimed for in patients with a 10-year risk of heart attack or stroke over 10%. Anyone who has already had a heart attack, stroke or even just a TIA (transitory ischemic attack) is also one of the people at very high risk. This group also includes people who have coronary artery disease (CHD, coronary artery disease), peripheral arterial disease (circulatory disorder in the legs), an enlargement of the abdominal aorta (aortic aneurysm), severe kidney weakness (GFR less than 30 ml), a narrowing of the carotid artery ( Carotid stenosis) or diabetes mellitus with consequential damage (e.g. protein in the urine). If diabetics smoke or also have high blood pressure, there is also a very high risk.

The following findings in the cardiovascular check lead to classification in this highest risk group:

  • Pronounced plaques (calcifications) in the cervical or inguinal vessels
  • Increased pulse wave velocity of the vessels
  • Calcium score over 100 on cardiac CT

If the risk is very high, the LDL cholesterol should be reduced to below 55 mg / dl (1.4 mmol / l) or by at least 50%. This means that with an LDL value of 120 mg / dl without therapy, an LDL value of less than 60 mg / dl should be aimed for.

If the risk is very high, the following guidelines apply:

  • Total cholesterol <180 mg / dl = 4.64 mmol / l
  • LDL <55 mg / dl = 1.4 mmol / l (or reduction by 50%)
  • HDL at least 40 mg / dl (women: 48 mg / dl)
  • Apolipoprotein A1> 120 mg / dl (women> 140 mg / dl)
  • Triglycerides <150 mg / dl = 1.69 mmol / l
  • Non-HDL cholesterol <85 mg / dl
  • Apolipoprotein B <60 mg / dl

If, despite therapy, a second event such as heart attack or stroke occurs within two years, the LDL should even be reduced to below 40 mg / dl (1.0 mmol / l).

Overview of target LDL cholesterol levels

  • Low risk: LDL <116 mg / dl
  • Medium risk: LDL <100 mg / dl
  • High risk: LDL <70 mg / dl
  • Very high risk: LDL <55 mg / dl
  • After the second event: LDL <40 mg / dl

The cholesterol values ​​do not have to be determined on an empty stomach, as the cholesterol level is only insignificantly influenced by food intake. The triglyceride values, however, are on average 30 mg higher after eating.

Additional special laboratory tests

The usual laboratory values ​​such as total cholesterol, HDL and LDL cholesterol and triglycerides are often not sufficient for an individual risk assessment. Additional information is provided by measuring non-HDL cholesterol, apolipoprotein B, apolipoprotein A1 and lipoprotein (a). These additional laboratory values, which are also important for therapy, are usually only determined in special cholesterol centers.

Different guidelines

The currently valid guidelines date from 2019 and are a joint recommendation of the European Society of Cardiology (ESC) and the European Atherosclerosis Society (EAS): https://academic.oup.com/eurheartj/article/41/1/111 / 5556353

The previous recommendations of the ESC / EAS from 2016:

The German Society for Cardiology (DGK) continued to recommend the therapy based on defined target values ​​and referred to the similarities between the two guideline concepts. The target values ​​(recommendation of the European societies) can usually only be achieved with higher doses of statins (recommendation of the US guidelines).

At the congress of the European Society of Cardiology (ESC) in 2015, experts called for a lowering of the target value for LDL cholesterol, as the new PCSK9 inhibitors would make this possible.

The different guidelines do not make the treatment of high cholesterol levels any easier. It is therefore advisable, in case of doubt, to seek the advice of doctors who have dealt intensively with this topic. Some practices offer special cholesterol consultations.

When the cholesterol levels are too low

On the other hand, cholesterol levels that are too low can occur due to:

In this respect, cholesterol levels that are too low can also be signs of illness and require medical clarification.

The American Heart Association (AHA) recommendations on cholesterol are updated regularly.