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Heart health insights: understanding cholesterol
Cholesterol Made Clear: What Matters for Your Heart
Dr Primero Ng, Interventional Cardiologist
Cholesterol is one of the most talked-about topics in heart health, yet also one of the most misunderstood. Many people feel anxious when they see an elevated cholesterol result, while others are unsure what the numbers actually mean. The truth is that cholesterol is not inherently bad, and a single result rarely tells the whole story.
In this article, we break down what cholesterol really is, how it affects your heart, and how to interpret your results in a way that is clear, practical, and focused on your individual cardiovascular risk.
The Essentials
Cholesterol: What It Is and Why It Matters for Your Heart
Cholesterol is a natural, waxy substance found in every cell of your body. Despite its reputation, cholesterol is not inherently harmful and is essential for normal bodily function. Your liver produces most of the cholesterol you need, with a smaller amount coming from the foods you eat.
Cholesterol plays several important roles. It helps form and maintain cell membranes, serves as a building block for key hormones such as oestrogen, testosterone, and cortisol, and is required for the production of vitamin D and bile acids, which assist with fat digestion.
The link between cholesterol and heart health is more complex than many people realise. Not all cholesterol is “bad”, and understanding the different types of cholesterol is crucial for making informed decisions about your cardiovascular health.

Key Functions of Cholesterol
  • Helps build and maintain healthy cell membranes
  • Acts as a building block for essential hormones
  • Supports vitamin D production
  • Aids fat digestion through bile acids
Cholesterol attracts medical attention because of its role in atherosclerosis, the gradual build-up of plaque within the arteries that can lead to heart attacks and strokes. However, cholesterol is only one part of the overall cardiovascular risk picture. Its significance needs to be interpreted alongside other factors such as blood pressure, diabetes, smoking history, genetics, and lifestyle, within the context of your individual health profile.
Cholesterol Types
Different Types of Cholesterol Explained
Cholesterol moves through your bloodstream in particles called lipoproteins. Each type plays a different role in the body and has different implications for heart health. Understanding these differences can help you make sense of your cholesterol results and have more informed discussions with your healthcare team.
LDL Cholesterol
Often referred to as “bad” cholesterol, LDL carries cholesterol from the liver to tissues throughout the body, including the walls of the arteries. When LDL levels are too high, cholesterol can gradually build up in the artery walls, increasing the risk of heart attack and stroke over time.
Optimal level: generally below 2.6 mmol/L, with lower targets recommended for people at higher cardiovascular risk.
HDL Cholesterol
Often called “good” cholesterol, HDL helps transport excess cholesterol away from the arteries and back to the liver, where it can be processed and removed. Higher HDL levels are generally associated with a lower risk of heart disease.
Healthy level: generally above 1.0 mmol/L in men and above 1.3 mmol/L in women.
Triglycerides
Triglycerides are the main form of fat in the bloodstream and are used by the body for energy. When levels are elevated, particularly in combination with low HDL cholesterol, they are associated with a higher risk of cardiovascular disease.
Normal level: generally below 1.7 mmol/L.
advanced cholesterol markers
Advanced Cholesterol Markers: Looking Beyond the Basics
Standard cholesterol tests provide valuable information and are an important first step in assessing heart health. In some people, however, these results do not fully explain their cardiovascular risk. In these situations, advanced cholesterol markers can offer a more complete and personalised picture.
These tests are particularly helpful if you have a strong family history of heart disease, diabetes, elevated triglycerides, or if treatment decisions are not straightforward.
Non-HDL Cholesterol
Non-HDL cholesterol represents all cholesterol particles that can contribute to plaque build-up in the arteries. It includes LDL cholesterol as well as other harmful lipoproteins.
It is calculated by subtracting HDL cholesterol from total cholesterol and is especially useful when triglyceride levels are elevated.
Typical targets:
  • Below 3.4 mmol/L for most adults
  • Below 2.6 mmol/L for people at higher cardiovascular risk
Because it captures all atherogenic particles, non-HDL cholesterol is often a more reliable marker than LDL alone.
Apolipoprotein B (ApoB)
ApoB measures the number of cholesterol-carrying particles in the bloodstream. Each plaque-forming particle contains exactly one ApoB molecule, making this a very accurate indicator of cardiovascular risk.
In some people, ApoB can better reflect risk than LDL cholesterol, particularly when cholesterol particles are small or triglycerides are elevated.
Typical targets:
  • Below 0.9 g/L for general risk
  • Below 0.7 g/L for high risk
  • Below 0.6 g/L for very high risk
ApoB is increasingly used to guide personalised treatment decisions.
Lipoprotein(a)
Lipoprotein(a), often written as Lp(a), is a genetically determined cholesterol particle that independently increases cardiovascular risk.
Unlike other cholesterol markers, Lp(a) levels are largely inherited and are not significantly affected by diet, exercise, or standard cholesterol medications.
Elevated level:
  • Above 125 nmol/L
People with high Lp(a) benefit from earlier risk assessment and more proactive management of other modifiable risk factors.

Why These Markers Matter
Advanced cholesterol markers help move beyond a one-size-fits-all approach. They allow your healthcare team to better understand your individual risk and tailor prevention or treatment strategies accordingly.
If these tests are relevant for you, your doctor can help interpret the results in the context of your overall cardiovascular health.
Risk Assessment
How Cholesterol Affects Your Cardiovascular Risk
Cholesterol levels provide important insight into heart health, but they do not tell the whole story. Your overall cardiovascular risk is shaped by a combination of factors, including age, blood pressure, diabetes, smoking history, and family background. Understanding how these elements interact allows cholesterol results to be interpreted in context, leading to more accurate risk assessment and more personalised care.
33%
Reduced Heart Attack Risk
Statin therapy can reduce myocardial infarction risk by approximately one-third in at-risk adults
22%
Stroke Prevention
Risk of stroke decreases with appropriate cholesterol management
1/250
Familial Hypercholesterolaemia
Affects about 1 in 250 people, causing markedly elevated cholesterol from birth
The Pooled Cohort Equations help your healthcare provider estimate your risk of developing cardiovascular disease over the next 10 years by considering multiple factors together, not cholesterol alone. This personalised risk assessment helps guide treatment decisions, with more intensive prevention strategies recommended for people at higher overall risk.
"Heart risk is driven by how long LDL cholesterol stays high, not just how high it gets. Early action lowers lifetime risk."
what causes high cholesterol
What Causes High Cholesterol?
High cholesterol rarely has a single cause. It most often reflects a combination of genetic predisposition, lifestyle factors, and, in some cases, underlying medical conditions. Understanding these contributing factors helps you and your healthcare provider develop an effective, personalised approach to managing your cholesterol and reducing long-term cardiovascular risk.
Genetic Factors
Some people are genetically predisposed to higher cholesterol levels. The most well-known inherited condition is familial hypercholesterolaemia (FH), which affects around 1 in 250 people. FH results from genetic changes that impair how the body clears LDL cholesterol, often leading to LDL levels above 4.9 mmol/L from a young age.
More commonly, cholesterol levels are influenced by the combined effect of multiple genetic variations, a pattern known as polygenic hypercholesterolaemia. This can result in mild to moderate, and sometimes more significant, cholesterol elevation, even in people who follow a healthy lifestyle.
Lifestyle Influences
Dietary patterns high in saturated fats, trans fats, and refined carbohydrates can raise cholesterol levels over time. Physical inactivity, excess body weight, and tobacco use can further worsen cholesterol levels and increase overall cardiovascular risk.
The encouraging news is that these factors are highly modifiable. Improving lifestyle habits forms the foundation of both cholesterol prevention and treatment, and even small, sustainable changes can lead to meaningful improvements in heart health.
Medical Conditions
Some medical conditions can raise cholesterol levels and should be considered before diagnosing a primary cholesterol disorder. Common causes include an underactive thyroid, kidney disease, diabetes, liver conditions, and certain medications, such as corticosteroids or some blood pressure treatments.
Identifying and treating these underlying factors can sometimes improve or normalise cholesterol levels, and may reduce or remove the need for long-term cholesterol-lowering medication.
Testing & Results
Understanding Your Cholesterol Test Results
Cholesterol testing usually starts with a standard lipid profile, which measures total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides. In most situations, testing can be performed without fasting, making it more convenient while still providing accurate and reliable results.
When Should Cholesterol Be Tested?
  • Adults aged 40 to 75: routine screening as part of a cardiovascular risk assessment
  • Younger adults with risk factors: such as a family history of heart disease, diabetes, or other medical conditions
  • After starting or adjusting treatment: typically after 4 to 12 weeks to assess response
  • Ongoing monitoring: every 3 to 12 months, depending on individual risk and treatment goals
Cholesterol results should always be interpreted in the context of your overall cardiovascular risk rather than as isolated numbers. What is considered optimal for one person may be different for another, depending on factors such as age, medical history, and overall heart disease risk.
Beyond Standard Tests
Advanced cholesterol testing, such as ApoB or lipoprotein(a), is not required for everyone but can be helpful in certain situations. These tests may be considered if:
  • You have a family history of early heart disease
  • Your triglyceride levels are significantly elevated
  • Treatment decisions are unclear
  • Standard cholesterol results do not fully explain your overall cardiovascular risk
Your healthcare provider can advise whether these tests would add useful information in your individual situation.

Coronary Artery Calcium Scoring
For people at intermediate cardiovascular risk, coronary calcium scoring can clarify risk and guide treatment. A score of zero indicates very low short-term heart attack risk, while higher scores signal greater plaque burden and the need for stronger prevention.
Your Personalised Management Plan
There is no one-size-fits-all approach to managing cholesterol. Your plan should be tailored to your individual risk, preferences, and circumstances. A heart-healthy lifestyle forms the foundation for everyone, with medication added when appropriate based on your personal cardiovascular risk and goals.
1
Live Heart Healthy
Prioritise vegetables, fruits, whole grains, nuts, and lean proteins, especially fish. Limit processed foods, sugary drinks, and unhealthy fats. Aim for at least 150 minutes of moderate exercise each week.
2
Know Your Risk
Your overall heart risk is assessed using your age, cholesterol, blood pressure, diabetes status, and smoking history, not cholesterol alone.
3
Use Medications When Needed
For higher-risk individuals, cholesterol-lowering medication can significantly reduce heart attack and stroke risk. Treatment intensity is tailored to your personal risk.
4
Track Your Progress
Regular blood tests and follow-up visits confirm your plan is working and allow early adjustment if needed.
5
Adapt Over Time
Your plan evolves as your health changes, ensuring ongoing, personalised heart protection.
"Managing cholesterol works best when you and your Cardiologist work together.
Your choices and commitment make the difference."
Making Decisions Together
Your Cholesterol Treatment Options
When lifestyle changes alone aren't sufficient, medication can significantly reduce your cardiovascular risk. Statins are the most extensively studied and effective cholesterol-lowering drugs, with decades of evidence supporting their benefits in preventing heart attacks and strokes.
When Is Medication Recommended?
Cholesterol-lowering medication is recommended when the expected benefits clearly outweigh the risks. This decision is based on your overall cardiovascular risk, not cholesterol levels alone, and is guided by national and international guidelines.
Medication is generally recommended in the following situations:
  • Very high LDL cholesterol (≥4.9 mmol/L):
    This level suggests a high lifetime risk of cardiovascular disease. Cholesterol-lowering medication, usually a statin, is typically recommended regardless of other risk factors.
  • Diabetes (aged 40 to 75):
    People with diabetes have a higher risk of heart disease. Moderate- to high-intensity statin therapy is usually advised, depending on overall risk and additional factors.
  • Elevated 10-year cardiovascular risk (≥7.5%):
    If your estimated risk of heart attack or stroke over the next 10 years is in this range, statin therapy is commonly recommended to reduce that risk.
  • Borderline risk (5 to 7.5%):
    Medication may be considered if additional risk-enhancing factors are present, such as a strong family history of heart disease, elevated lipoprotein(a), or evidence of coronary artery calcium.

Lifestyle First, Medication If Needed
If your overall cardiovascular risk is low or your cholesterol is only mildly elevated, lifestyle changes are often sufficient. Medication is usually not required immediately, and regular monitoring allows your care plan to be adjusted if your risk changes.
1
Initial Assessment
A full review of your cardiovascular risk and a shared discussion about the best treatment options for you.
2
4–12 Weeks
First follow-up to check how well treatment is working and address any side effects or concerns.
3
Every 3–12 Months
Ongoing monitoring, tailored to your risk level and response to treatment.
4
Long-Term Care
An ongoing partnership with your healthcare team to keep your heart protected over time.

Statins: Safety and Side Effects
Most people tolerate statins well, and serious side effects are uncommon. Mild muscle aches occur in around 5 to 10% of people and often improve with dose adjustment or a different statin. For those at higher cardiovascular risk, the proven benefits in preventing heart attack and stroke far outweigh the potential risks.
Take Charge of Your Heart Health
Understanding your cholesterol helps you reduce risk, make informed choices, and work confidently with your healthcare team to protect your heart.
Lifestyle Comes First
Healthy eating, regular activity, weight management, and avoiding tobacco are the foundation of heart health for everyone.
Personalised Care
Cholesterol management is tailored to you. Your risk, preferences, and circumstances guide decisions, not a single universal target.
Prevention Works
Strong evidence shows that lowering LDL cholesterol reduces heart attacks, strokes, and cardiovascular deaths in people at risk.
You’re Supported
Your healthcare team partners with you at every stage, from assessment to long-term follow-up and treatment adjustments.
Mildly elevated cholesterol in someone without other risk factors often requires only lifestyle changes and regular monitoring. In contrast, people with multiple risk factors or established heart disease may benefit from more intensive treatment. The most important step is understanding your personal risk and working in partnership with your healthcare provider to create a plan that is right for you.
"Understanding cholesterol empowers you to make personalised choices that protect your heart and reduce long-term risk."
© 2026 Dr Primero Ng. All rights reserved.
Consultant Interventional Cardiologist, Perth, Western Australia.
Information on this website is general in nature and does not replace individual medical advice.