Cholesterol Medicines

What is cholesterol?

Cholesterol is a waxy, fat-like substance that's found in all the cells in your body. Your body needs some cholesterol to work properly. But if you have too much of it in your blood, it can stick to the walls of your arteries and narrow or even block them. This puts you at risk for coronary artery disease and other heart diseases.

Cholesterol is made by your liver. It travels through the blood on proteins called lipoproteins. One type of lipoprotein, LDL, is sometimes called the "bad" cholesterol. A high LDL level leads to a buildup of cholesterol in your arteries. Another type, HDL, is sometimes called the "good" cholesterol. It carries cholesterol from other parts of your body back to your liver. Then your liver removes the cholesterol from your body.

What are the treatments for high cholesterol?

If you have high cholesterol, lifestyle changes can help you lower your cholesterol levels. But sometimes the lifestyle changes are not enough, and you need to take cholesterol medicines. But you should still continue with the lifestyle changes even though you are taking medicines.

Who needs cholesterol medicines?

Your health care provider may prescribe cholesterol medicines for you if:

• You have already had a heart attack or stroke, or you have peripheral arterial disease
• Your LDL (bad) cholesterol level is 190 mg/dL or higher
• You are 40-75 years old, you have diabetes, and your LDL cholesterol level is 70 mg/dL or higher
• You are 40-75 years old, you have a high risk of developing heart disease or stroke, and your LDL cholesterol level is 70 mg/dL or higher

What are the different types of cholesterol medicines?

There are several types of cholesterol-lowering drugs available, including:

• Statins. They reduce the amount of cholesterol made in the liver. They also increase your liver's ability to remove LDL cholesterol that is already in the blood. Statins are the most common medicines used to treat high cholesterol.
• Bile acid sequestrants. They keep bile acids, which digest fats and oils, from being absorbed into the body. But your body needs bile acids, so your liver will make more of them. It makes them by breaking down LDL cholesterol, so this helps lower your LDL cholesterol. Your provider may prescribe these medicines if you cannot take statins or if statins alone are not lowering your cholesterol enough.
• Cholesterol absorption inhibitors. They block how cholesterol is absorbed into the body. They are also used if you cannot take statins or if statins alone are not lowering your cholesterol enough.
• Nicotinic acid (niacin). It is a type of B vitamin. It reduces the amount of fats made by your liver, so it lowers your LDL cholesterol and triglycerides. Niacin also raises HDL cholesterol. Even though you can buy niacin without a prescription, you should talk to your provider before taking it to lower your cholesterol. High doses of niacin can cause serious side effects.
• PCSK9 inhibitors. These are medicines that you inject under your skin. They block a protein called PCSK9. This helps your liver remove and clear LDL cholesterol from your blood. Your provider may prescribe a PCSK9 inhibitor and a statin if you are at high risk of complications like heart attack or stroke, or if you have familial hypercholesterolemia (FH). FH is an inherited disorder that causes very high levels of cholesterol in the blood.
• Fibrates. They lower triglycerides in several complex ways, including reducing the amount of triglycerides made by the liver. They may also help increase HDL cholesterol and may lower LDL levels a bit. If you take them with statins, it might increase the risk of side effects.
• Combination medicines. They include more than one type of cholesterol-lowering medicine. There are also combination medicines that can treat both high blood pressure and cholesterol.

There are also a few other cholesterol medicines (lomitapide and mipomersen) that are only for people who have FH.

How does my health care provider decide which cholesterol medicine I should take?

When deciding which medicine you should take and which dose you need, your provider will consider:

• Your cholesterol levels.
• Your risk for heart disease and stroke.
• Your age.
• Any other health problems you have.
• Possible side effects of the medicines. Higher doses are more likely to cause side effects, especially over time.

Medicines can help control your cholesterol, but they don't cure it. You need to keep taking your medicines and get regular cholesterol checks to make sure that your cholesterol levels are in a healthy range.

Arteriovenous Malformations

What are arteriovenous malformations (AVMs)?

Arteriovenous malformations (AVMs) are defects in your vascular system. Your vascular system is your body's network of blood vessels. It includes your:

• Arteries, which carry oxygen-rich blood from your heart to your tissues and organs.
• Veins, which carry the blood and waste products back to your heart.
• Capillaries, which are tiny blood vessels that connect your small arteries to your small veins.

An AVM is an abnormal tangle of arteries and veins. They are connected to each other, with no capillaries between them. Without the capillaries, the blood flow from the arteries goes directly into the veins at a faster rate than normal. Because of this, the nearby tissue does not get all the oxygen it would normally get. This lack of oxygen can lead to tissue damage and the death of nerve cells and other cells. The fast rate of blood flow can also increase the blood pressure inside the arteries and veins. This can weaken the arteries and veins. A weakened artery or blood vessel could burst or leak blood.

What causes arteriovenous malformations (AVMs)?

AVMs are rare. The cause of AVMs is unknown. Most of the time, people are born with them. But sometimes they can appear shortly after birth or later in life.

What are the symptoms of arteriovenous malformations (AVMs)?

The symptoms of AVM will depend on where the AVM is located. They can happen anywhere in the body, but they are more common in the brain or spinal cord. Most people with brain or spinal cord AVMs have few, if any, major symptoms. But if a weakened blood vessel bursts, it can spill blood into the brain (called a hemorrhage). Severe hemorrhages can cause a stroke and brain damage.

If an AVM is causing symptoms, they can include:

• Seizures
• Headache
• Pain in the area where the AVM is located
• Vision problems
• Muscle weakness
• Problems with movement and speech
• Confusion
• Dizziness
• Loss of consciousness

How are arteriovenous malformations (AVMs) diagnosed?

To find out if you have an AVM, your health care provider:

• Will ask about your symptoms and medical history.
• Will do a physical exam. This may include listening for a bruit. A bruit is whooshing sound caused by the rapid blood flow through the arteries and veins of an AVM.
• May order imaging tests, such as a CT scan, MRI, ultrasound, or cerebral angiography. For a cerebral angiography, you are injected with a special dye that helps the blood vessels in your brain show up on x-rays.

What are the treatments for arteriovenous malformations (AVMs)?

Treatments for AVMs will depend on factors such as:

• Where the AVM is located
• Its size
• Your symptoms
• Your overall health
• Your risk of bleeding

The treatment options may include:

• Monitoring for any signs that may mean you have an increased risk of hemorrhage.
• Medicines to help with the symptoms from AVMs.
• Surgery, which may be done if you have a higher-than-usual risk of bleeding. There are a few different types of surgery for AVMs. In some cases, you may have more than one type. Surgery can be risky, especially when it's done on the brain or spinal cord. So you and your provider will need to discuss the risks and benefits of doing the surgery before you make a decision.

NIH: National Institute of Neurological Disorders and Stroke

Atherosclerosis

What is atherosclerosis?

Atherosclerosis is a condition in which plaque builds up inside your arteries. Plaque is a sticky substance made up of cholesterol, fat, blood cells, calcium, and other substances found in the blood. Over time, plaque hardens and causes your arteries to narrow. That limits the flow of oxygen-rich blood to your body.

Some people may confuse atherosclerosis and arteriosclerosis, but they are not the same thing:

• Arteriosclerosis is hardening of the arteries, which means that the arteries thicken and become less flexible. It can have several different causes.
• Atherosclerosis, which develops from plaque buildup, is a common type of arteriosclerosis.

Atherosclerosis can affect most of the arteries in the body. It has different names, based on which arteries are affected:

• Coronary artery disease (CAD) is plaque buildup in the arteries of your heart.
• Peripheral artery disease (PAD) is plaque buildup in the arteries that carry blood away from the heart to other parts of the body. It most often affects the arteries of your legs, but it can also affect the arteries of your arms or pelvis.
• Carotid artery disease is plaque buildup in the neck arteries. It reduces blood flow to the brain.
• Renal artery stenosis is plaque buildup in the arteries that supply blood to your kidneys.
• Vertebral artery disease is plaque buildup in the arteries that supply blood to the back of your brain.
• Mesenteric artery ischemia is plaque buildup in the arteries that supply your intestines with blood.

What causes atherosclerosis?

Plaque often starts to build up during childhood and gets worse with age. The exact cause is unknown, but researchers believe that this buildup happens when there is damage to the arteries. This damage may be caused by unhealthy lifestyle habits, medical conditions, and your genes.

Who is more likely to develop atherosclerosis?

You may be more likely to develop atherosclerosis if you:

• Have certain medical conditions, including:
  • High blood pressure
  • High blood cholesterol
  • Diabetes
  • Metabolic syndrome
  • Inflammatory diseases such as rheumatoid arthritis and psoriasis
• Have a family history of high blood cholesterol
• Eat a lot of foods high in saturated fats
• Smoke or chew tobacco
• Are older - the risk increases after age 45 men and age 55 in women

What are the symptoms of atherosclerosis?

In the early stages, atherosclerosis often does not cause any symptoms. You may first notice some symptoms at times when your body needs more oxygen. For example, this could be when you are having physical or emotional stress.

Your symptoms will depend on which arteries are affected and how much blood flow is blocked:

• With coronary artery disease, the symptoms may include angina (a type of chest pain), palpitations (racing or pounding heart), and shortness of breath.
• With carotid artery disease, you may have a bruit. This is a whooshing sound that your health care provider hears when using a stethoscope. You could also have a transient ischemic attack (TIA), sometimes called a mini-stroke.
• With peripheral artery disease, you may have pain, aching, heaviness, or cramping in the legs when walking or climbing stairs.
• With vertebral artery disease, you may have problems with thinking and memory, weakness or numbness on one side of the body or face, and vision trouble. You could also have a transient ischemic attack.
• With mesenteric artery ischemia, the symptoms can include severe pain after meals, weight loss, and diarrhea.

For men, erectile dysfunction (ED) is an early warning sign that you may be at higher risk for atherosclerosis and its complications. If you have ED, talk with your provider about your risk of plaque buildup.

What other problems can atherosclerosis cause?

Atherosclerosis can cause other health problems, or complications. For example, if a plaque bursts, a blood clot may form. The clot could block the artery completely or travel to another part of the body. Other possible complications can vary, depending on which arteries are affected. For example, blockages in different parts of the body can lead to complications such as a heart attack, stroke, vascular dementia, or limb loss.

How is atherosclerosis diagnosed?

To find out if you have atherosclerosis, your provider:

• Will ask about your medical and family health history
• Will ask about your lifestyle and risk factors for plaque buildup in the arteries
• Will do a physical exam, which will include listening to your heart and the blood flow in your arteries
• Will likely order tests, such as blood tests and heart health tests

What are the treatments for atherosclerosis?

If you have atherosclerosis, your provider will work with you to create a treatment plan that works for you. Your plan will depend on which arteries are affected, how much the blood flow is blocked, and what other medical conditions you have. Possible treatments may include:

• Heart-healthy lifestyle changes.
• Medicines to:
  • Manage your risk factors.
  • Treat atherosclerosis or its complications.
  • Treat any medical conditions you have that can worsen plaque buildup.
• Procedures or surgeries to treat diseases or complications that were caused by plaque buildup. The specific type of procedure or surgery will depend on which arteries are affected.
• Cardiac rehabilitation, if you have had certain complications from atherosclerosis.

Can atherosclerosis be prevented?

There are steps you can take to try to prevent atherosclerosis:

• Choose heart-healthy foods, such fruits, vegetables, and whole grains. Limit foods that are high in saturated fats, salt, and added sugars.
• Do regular physical activity. But before you start an exercise program, ask your provider what level of physical activity is right for you.
• Aim for a healthy weight.
• Limit how much alcohol you drink. Drinking less is better for health than drinking more. Men should limit their intake to 2 drinks or less in a day. Women should drink 1 drink or less per day.
• Manage stress.
• If you smoke, quit smoking.
• Avoid secondhand smoke.
• Get enough good-quality sleep.

NIH: National Heart, Lung, and Blood Institute

Cholesterol

What is cholesterol?

Cholesterol is a waxy, fat-like substance that's found in all the cells in your body. Your body needs some cholesterol to make hormones, vitamin D, and substances that help you digest foods. Your body makes all the cholesterol it needs. Cholesterol is also found in foods from animal sources, such as egg yolks, meat, and cheese.

If you have too much cholesterol in your blood, it can combine with other substances in the blood to form plaque. Plaque sticks to the walls of your arteries. This buildup of plaque is known as atherosclerosis. It can lead to coronary artery disease, a condition in which your coronary arteries become narrow or even blocked.

What are HDL, LDL, and VLDL?

HDL, LDL, and VLDL are lipoproteins. They are a combination of fat (lipid) and protein. The lipids need to be attached to the proteins so they can move through the blood. Different types of lipoproteins have different purposes:

• HDL stands for high-density lipoprotein. It is sometimes called "good" cholesterol because it helps your body get rid of cholesterol. It carries cholesterol from other parts of your body back to your liver. Your liver then removes the cholesterol from your body.
• LDL stands for low-density lipoprotein. It is sometimes called "bad" cholesterol because a high LDL level leads to the buildup of plaque in your arteries.
• VLDL stands for very low-density lipoprotein. Some people also call VLDL a "bad" cholesterol because it too contributes to the buildup of plaque in your arteries. But VLDL and LDL are different; VLDL mainly carries triglycerides and LDL mainly carries cholesterol.

What causes high cholesterol?

The most common cause of high cholesterol is an unhealthy lifestyle. This can include:

• Unhealthy eating habits, such as eating lots of saturated fats. These fats are found in red meats, full-fat dairy products, chocolate, some baked goods, and many deep-fried and processed foods. Eating too much saturated fat can raise your LDL (bad) cholesterol.
• Lack of physical activity, with lots of sitting and little exercise. This lowers your HDL (good) cholesterol.
• Smoking, which lowers HDL cholesterol, especially in women. It also raises your LDL cholesterol.
• Stress, which may raise levels of certain hormones such as corticosteroids. These can cause your body to make more cholesterol.
• Drinking too much alcohol, which can raise your total cholesterol level.

Genetics may also cause people to have high cholesterol. For example, familial hypercholesterolemia (FH) is an inherited condition that causes very high levels of cholesterol in the blood. Other medical conditions and certain medicines may also raise LDL cholesterol levels or lower HDL cholesterol levels.

What can raise my risk of high cholesterol?

A variety of things can raise your risk of high cholesterol:

• Age. Your cholesterol levels tend to rise as you get older. Even though it is less common, younger people, including children and teens, can also have high cholesterol.
• Sex. Between ages 20 and 39, men have a greater risk of high total cholesterol than women. But after menopause, a woman's risk goes up. This happens because menopause lowers levels of female hormones that may protect against high blood cholesterol.
• Family history. High blood cholesterol can run in families.
• Other health conditions. Conditions such as diabetes, chronic kidney disease, HIV, and lupus can raise your risk of high cholesterol.
• Medicines. Certain medicines can raise your level of LDL cholesterol or lower your level of HDL cholesterol, including:
  • Steroids
  • Some chemotherapy medicines
  • Medicines taken after an organ transplant
  • Medicines for certain heart conditions
  • Certain acne medicines
• Race or ethnicity. People from certain racial or ethnic groups may have an increased risk of high cholesterol. For example, Asian Americans are more likely to have high levels of LDL cholesterol than other groups. And non-Hispanic White people are more likely than other groups to have high levels of total cholesterol.
• Weight. Being overweight or having obesity raises your cholesterol level.

What other health problems can high cholesterol cause?

Undiagnosed or untreated high blood cholesterol can lead to serious health problems:

• If you have large deposits of plaque in your arteries, an area of plaque can rupture (break open). This can cause a blood clot to form on the surface of the plaque. If the clot becomes large enough, it can mostly or completely block blood flow in a coronary artery.
• If the flow of oxygen-rich blood to your heart muscle is reduced or blocked, it can cause angina (chest pain) or a heart attack.
• Plaque also can build up in other arteries in your body, including the arteries that bring oxygen-rich blood to your brain and limbs. This can lead to problems such as carotid artery disease, stroke, and peripheral arterial disease.

How is high cholesterol diagnosed?

There are usually no signs or symptoms that you have high cholesterol. A blood test can measure your cholesterol levels. When and how often you should get this test depends on your age, risk factors, and family history. The general recommendations are:

For people who are age 19 or younger:

• The first test should be between ages 9 to 11
• Children should have the test again every 5 years
• Some children may have this test starting at age 2 if there is a family history of high blood cholesterol, heart attack, or stroke

For people who are ages 20 to 65:

• Younger adults should have the test every 5 years
• Men ages 45 to 65 and women ages 55 to 65 should have it every 1 to 2 years

For people over age 65:

• They should be tested every year

How can I lower my cholesterol?

You can lower your cholesterol through heart-healthy lifestyle changes. They include a heart-healthy eating plan, weight management, and regular physical activity.

If the lifestyle changes alone do not lower your cholesterol enough, you may also need to take medicines. There are several types of cholesterol-lowering medicines available, including statins. If you take medicines to lower your cholesterol, you still should continue with the lifestyle changes.

Some people with familial hypercholesterolemia (FH) may receive a treatment called lipoprotein apheresis. This treatment uses a filtering machine to remove LDL cholesterol from the blood. Then the machine returns the rest of the blood back to the person.

NIH: National Heart, Lung, and Blood Institute

Diabetes Complications

What is diabetes?

If you have diabetes, your blood glucose, or blood sugar, levels are too high. Glucose comes from the foods you eat. A hormone called insulin helps the glucose get into your cells to give them energy.

With type 1 diabetes, your body does not make insulin. With type 2 diabetes, your body does not make or use insulin well. Without enough insulin, the glucose stays in your blood.

What health problems can diabetes cause?

Over time, having too much glucose in your blood can cause complications, including:

• Eye disease, due to changes in fluid levels, swelling in the tissues, and damage to the blood vessels in the eyes.
• Foot problems, caused by damage to the nerves and reduced blood flow to your feet.
• Gum disease and other dental problems, because a high amount of glucose in your saliva helps harmful bacteria grow in your mouth. The bacteria combine with food to form a soft, sticky film called plaque. Plaque also comes from eating foods that contain sugars or starches. Some types of plaque cause gum disease and bad breath. Other types cause tooth decay and cavities.
• Heart disease and stroke, caused by damage to your blood vessels and the nerves that control your heart and blood vessels.
• Kidney disease, due to damage to the blood vessels in your kidneys. Many people with diabetes develop high blood pressure. That can also damage your kidneys.
• Nerve problems (diabetic neuropathy), caused by damage to the nerves and the small blood vessels that nourish your nerves with oxygen and nutrients.
• Sexual and bladder problems, caused by damage to the nerves and reduced blood flow in the genitals and bladder.
• Skin conditions, some of which are caused by changes in the small blood vessels and reduced circulation. People with diabetes are also more likely to have infections, including skin infections.

What other problems can people with diabetes have?

If you have diabetes, you need to watch out for blood glucose levels that are too high (hyperglycemia) or too low for you (hypoglycemia). These can happen quickly and can become dangerous. Some of the causes include having another illness or infection and certain medicines. They can also happen if you don't get the right amount of diabetes medicines. To try to prevent these problems, make sure to take your diabetes medicines correctly, follow your diabetic diet, and check your blood glucose regularly.

NIH: National Institute of Diabetes and Digestive and Kidney Diseases