Hypercholesterolemia


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Classification according to ICD-10
E78.0 Pure hypercholesterolemia
ICD-10 online (WHO version 2019)

Under hypercholesterolemia is defined as a high cholesterol level in the blood . It is also used synonymously with hyperlipoproteinemia in some cases in the literature . In general, if the total cholesterol in the blood exceeds 200 mg / dl, the currently recommended limit , it is referred to as hypercholesterolemia. Depending on the method of determination, the blood is examined when fasting (12 hours after the last meal) or in patients who have not fasted . Hypercholesterolemia is regarded as a relevant risk factor, especially for arteriosclerosis . The additional determination of the subcategories HDL and LDL plays an important role in determining the value as an independent risk factor . The recommendations for the upper and lower limits of the measured values ​​with regard to the risk constellation have been adjusted several times in the past decades due to new study results. They are also dependent on additional risk factors as well as the age and previous illnesses of the affected patients. In Europe, for example, the ESC / EAS guidelines for the treatment of dyslipidemia are considered expert consensus . These describe the risk factors, risk assessment and treatment options for hypercholesterolemia.

causes

There are many causes of high cholesterol levels in the blood: hereditary diseases , but also diabetes , hypothyroidism , pancreatitis , nephrotic syndrome , certain liver diseases, obesity , alcoholism , pregnancy , the use of certain medications (for example contraceptives , corticosteroids and antiretrovirals in HIV therapy ) and eating disorders. High dietary cholesterol can increase LDL-C levels, but it is debatable whether this factor plays a major role as genetic factors are much more important.

(→ main article hyperlipoproteinemia and homozygous familial hypercholesterolemia )

Importance as a risk factor

Hypercholesterolemia is a risk factor for cardiovascular diseases such as heart attack, stroke or peripheral arterial disease. The target values ​​to be striven for depend on the presence of further risk factors and previous illnesses. In general, if the total cholesterol level in the blood is over 200 mg / dl, there should be a further differentiation into LDL (Low Density Lipoprotein) and HDL (High Density Lipoprotein) cholesterol, since LDL cholesterol is a risk factor (in layman's terms as "bad." Cholesterol "known). HDL cholesterol is sometimes referred to as "good cholesterol".

Prevention of Cardiovascular Events

Hypercholesterolemia is of particular importance as a risk factor for cardiovascular events (e.g. myocardial infarction ) , both in younger and older adults.

Primary prevention of stroke

Drug lipid lowering depends on the LDL level and the individual risk profile. If there are no additional risk indicators, the LDL value should be below 130 mg / dl (or therapeutically below this value) . If there is diabetes mellitus , an increased vascular risk or CHD , it should be below 100 mg / dl, and in high-risk patients even below 70 mg / dL. This value is also considered a risk factor for subarachnoid hemorrhage.

Secondary prevention of stroke

Hypercholesterolemia is considered to be the cause of the progression of arteriosclerosis , which can lead to a stroke - often in combination with hypertension and other risk factors. As a secondary prevention of stroke (i.e. after suffering a stroke) there is no evidence for a specific LDL target value. According to the expired S3 guideline of the German Society for Neurology, an LDL target value of <100 mg / dl should be aimed for based on cardiovascular studies.

Aneurysms

Hypercholesterolemia is classified as a "minor risk factor" for the development of abdominal aortic and pelvic artery aneurysms .

Further meaning

Hypercholesterolemia is considered a relative contraindication for the use of ovulation inhibitors . For the ketogenic diet (low-carbohydrate, energy- and protein-balanced and extremely high-fat diet - mimicking the metabolic state of fasting) , hypercholesterolemia is a contraindication.

treatment

Priority measures are weight loss and physical activity. A low-cholesterol, low-fat, calorie-adjusted and high-fiber diet can also be helpful. If the cholesterol level is not reduced sufficiently despite these measures, additional drug treatment with statins may be necessary. How much the cholesterol level should be lowered depends on the individual factors mentioned above and is explained in detail in the ESC / EAS guidelines.

So-called CSE inhibitors (cholesterol synthesis enzyme inhibitors) of the HMG-CoA reductase inhibitor type can be used to reduce LDL cholesterol by, among other things, inhibiting its formation in the liver . These drugs are known as statins . Other LDL-lowering drugs are the replacement resins ( colestyramine , colesevelam ) . Furthermore, there are the active ingredient groups of fibrates and nicotinic acid derivatives , which, however, have lost their importance in practice according to recent studies. [ESC guideline] Nicotinic acid derivatives are even no longer permitted in most countries. There is also ezetimibe , a selective cholesterol absorption inhibitor that, according to the ESC / EAS guidelines, can be used as a second-line or combination therapy for additional LDL cholesterol lowering. Since the end of 2015, two fully human antibodies against the protein proprotein convertase subtilisin / kexin type 9 , the PCSK9 inhibitors alirocumab and evolocumab, have been available for therapy-resistant cases with a high cardiovascular risk or a hereditary disorder of lipid metabolism . They lower LDL cholesterol by an average of 57%. As a last resort, LDL apheresis can also be used in the case of progressive cardiovascular disease under maximum lipid-lowering therapy . A US study by Georgetown University shows that the participants took grape seed extract with Chromium Polynicotinate to lower their cholesterol levels.

Prevention of Cardiovascular Events

A reduction in the rate of cardiovascular events by reducing existing hypercholesterolemia was found in various age groups and also in patients with type II diabetes mellitus.

Primary prevention of stroke

The benefit of statins has been statistically proven in high-risk patients, especially for the prevention of atherothrombosis, and is therefore also recommended for this group of patients.

Secondary prevention of stroke

After an ischemic stroke, statin therapy is recommended even if the cholesterol level is normal.

Individual evidence

  1. a b c Guideline for primary and secondary prevention of cerebral ischemia
  2. a b c d e Dyslipidaemias 2016 (Management of). ESC, accessed January 29, 2017 .
  3. ^ S1 guideline recommendations for antiretroviral therapy in HIV-infected children . In: AWMF online
  4. ^ S1 guideline on eating disorders . In: AWMF online
  5. Diagnosis and therapy of heart diseases in diabetes mellitus
  6. Guideline Diagnostics, Therapy and Monitoring of Diabetes Mellitus in Old Age
  7. ^ S1 guideline for subarachnoid hemorrhage . In: AWMF online
  8. Archive guidelines. Retrieved July 1, 2020 .
  9. ^ S2 Guideline for Abdominal Aortic Aneurysm (AAA) . In: AWMF online
  10. S1 guideline contraception . In: AWMF online
  11. S1 guideline Ketogenic Diet . In: AWMF online
  12. a b S1 guideline for primary and secondary prevention of cerebral ischemia . In: AWMF online
  13. MJ Lipinski, U. Benedetto, RO Escarcega and a .: The impact of proprotein convertase subtilisin-kexin type 9 serine protease inhibitors on lipid levels and outcomes in patients with primary hypercholesterolaemia: a network meta-analysis . In: Eur Heart J. . 2015. doi : 10.1093 / eurheartj / ehv563 . PMID 26578202 .
  14. English: Effects of niacin-bound chromium and grape seed proanthocyanidin extract on the lipid profile of hypercholesterolemic subjects: a pilot study. , accessed on March 23, 2020
  15. German: OPC grape seed extract studies: In the case of elevated cholesterol levels , accessed on March 23, 2020
  16. S3 guideline on stroke . In: AWMF online