High Cholesterol

Too much LDL (“bad”) cholesterol in the blood slowly builds fatty plaque inside the arteries. You can’t feel it, but it raises the risk of heart attack and stroke. More than 2 in 5 Australian adults have it, and lowering it works.

Symptoms

• Usually none. Most people find out from a routine blood test.
• The first sign can be angina (chest tightness on exertion), a heart attack or a stroke, which is why checking matters.
• Inherited high cholesterol can cause small fatty lumps under the skin.

Causes and risk factors

• Food high in saturated fat (fatty meat, butter, coconut and palm oil) and trans fat (deep-fried food, store-bought baked goods).
• Not moving much, carrying extra weight, smoking and heavy drinking.
• Diabetes, kidney disease and some medicines.
• Genes. Familial hypercholesterolaemia (FH) affects about 1 in 250 people and causes high cholesterol from birth, even with a perfect diet.
• Getting older. Risk rises with age for everyone.

How it’s diagnosed

• A blood test (lipid profile) measures total cholesterol, LDL, HDL (“good”) cholesterol and triglycerides. You may be asked to fast first.
• In Australia, get checked at least every 5 years from age 45, from 35 if you have diabetes, and from 30 for Aboriginal and Torres Strait Islander people.
• Your GP combines the result with your age, blood pressure, smoking and diabetes to estimate your chance of a heart attack or stroke in the next 5 years (a Heart Health Check). That risk, not the cholesterol number alone, decides whether you need medicine.
• Very high LDL, fatty lumps on the skin, or close family with heart disease at a young age? Ask about FH.

The cholesterol ladder

Food and exercise help everyone. Whether you need medicine depends on your overall heart risk. If you’ve had a heart attack or stroke, medicine is almost always the main event.

1. Step 1 · Self-careSwap the fats, add the fibreOlive or canola oil, nuts, avocado and fish instead of butter, fatty meat and coconut oil. More oats, legumes and psyllium. Move 30–60 minutes most days.

   Works

   Lowers LDL and helps weight and blood pressure too. Some people reach a safe level this way alone; others need medicine as well

   Cost

   Free, or a little extra on groceries

   How long

   Ongoing; recheck after a few months

   Watch for

   Inherited high cholesterol rarely responds enough to diet alone.

   Coconut oil is a saturated fat wearing a wellness outfit.

2. Step 2 · SupermarketPlant sterol-enriched foodsSpreads, milks or cereals with added plant sterols, eaten every day with meals.

   Works

   2–3 g a day (about 25 g of enriched spread) lowers LDL a little. A helper, not a replacement for a statin if you need one

   Cost

   A few dollars a week more than regular versions

   How long

   Daily, ongoing

   Watch for

   Only works while you keep eating it.

   Spreading it thicker doesn’t spread the benefit thicker.

3. Step 3 · PrescriptionStatins (atorvastatin, rosuvastatin and others)One tablet a day. The first choice when your risk is high, you have diabetes or kidney disease, or you’ve had a heart attack or stroke.

   Works

   Lower LDL by about 30–55%. Each 1 mmol/L drop in LDL cuts heart attacks and strokes by about a fifth

   Cost

   Under the $25 PBS co-payment, about $21–22 a month; $7.70 concession

   How long

   Long term, usually for life

   Watch for

   Muscle aches (in blinded trials most aches happened just as often on dummy tablets), a small rise in blood sugar. Get checked for unexplained muscle pain with dark urine.

   The best-studied tablet in the pharmacy with the worst reputation on the internet.

4. Step 4 · PrescriptionEzetimibeA daily tablet that blocks cholesterol absorption from the gut, added to a statin or used alone if statins don’t suit.

   Works

   Lowers LDL by about another 20%. Added to a statin after a heart attack, about 1 extra person in 50 avoided a heart attack, stroke or related event over about 7 years

   Cost

   Under the $25 PBS co-payment

   How long

   Long term

   Watch for

   Usually well tolerated. Combination tablets with a statin mean one less pill.

   The quiet sidekick. Not flashy, but it gets the job done.

5. Step 5 · SpecialistCholesterol injections (evolocumab)An injection every 2 or 4 weeks for people at very high risk whose LDL stays high despite tablets, including many with FH.

   Works

   Lowers LDL by about 60%. In a big trial on top of statins, heart attacks fell by about a quarter and strokes by about a fifth over a few years

   Cost

   $25 per script on the PBS ($7.70 concession), only for people who meet strict criteria

   How long

   Long term

   Watch for

   Injection-site soreness. Self-injected at home with a pen.

   For when tablets have done their best and it still isn’t enough.

6. Step 6 · SpecialistLipid clinic and family testing for FHA specialist confirms FH (sometimes with a gene test) and helps test parents, brothers, sisters and children.

   Works

   No trials of referral itself. Finding FH lets relatives be treated early, often decades before a heart attack would have happened

   Cost

   Specialist fees vary; Medicare rebates with a GP referral

   How long

   Until LDL is controlled, plus family testing

   Watch for

   Bring your highest cholesterol result and your family heart history.

   One diagnosis can protect a whole family tree.

Costs are rough Australian prices in November 2026 and vary by pharmacy and provider. PBS co-payment: $25, or $7.70 with a concession card. Results are typical figures from trials, not promises.

Save your money

Popular, heavily marketed or often asked about, but the evidence is weak or says no.

• Red yeast riceCan contain monacolin K, which is chemically the same as the statin lovastatin, in amounts that vary wildly between brands, and some products contain a kidney toxin. An unlabelled statin of unknown strength.
• Fish oil capsules for heart protectionA large Cochrane review of 79 trials found little or no effect on heart attacks, strokes or deaths. Eating fish is fine; capsules aren’t a shield.
• Coconut oilMostly saturated fat, which raises LDL. Swap it out, not in.
• Stopping your statin when the numbers look goodThe number is good because of the statin. Stop it and LDL climbs back. Talk to your GP before any change.

What you can do

• Book a Heart Health Check if you’re 45 or over (30 for Aboriginal and Torres Strait Islander people) and haven’t had one.
• Swap butter and fatty meats for olive oil, nuts, fish and legumes; that’s the change with the most evidence.
• Get your blood pressure checked too; it adds to the same risk.
• If you smoke, quitting lowers your heart risk more than almost anything else.
• Have FH? Make sure your parents, siblings and children get tested.
• On a statin? Recheck cholesterol about 6 weeks after starting or changing the dose.

See your GP if

• You’ve never had a cholesterol check and you’re 45 or over (35 with diabetes, 30 for Aboriginal and Torres Strait Islander people)
• A close relative had a heart attack or stroke young, or has very high cholesterol
• You notice fatty lumps on your skin
• You have side effects on treatment: there’s usually another option

Call 000 (Australia) or your local emergency number for chest pain, pressure or tightness, especially if it spreads to the arm, jaw or back or comes with breathlessness or sweating. Also for signs of stroke: face drooping, an arm that won’t lift, or slurred or muddled speech, even if they pass. From a mobile, 112 works in most countries.

Helpful resources

• Aus CVD Risk CalculatorThe official Australian heart attack and stroke risk calculator your GP uses. Bring your numbers and go through it together. Free.
• Healthdirect: How to lower cholesterolPlain-English food and lifestyle guide, plus a free 24-hour nurse line (1800 022 222). Australia.

Evidence and more information

• Healthdirect: High cholesterol
• Healthdirect: How to lower cholesterol
• 2023 Australian guideline for assessing and managing cardiovascular disease risk
• NHS (nidirect): High cholesterol
• Lancet (2012): Cholesterol Treatment Trialists’ statin meta-analysis
• IMPROVE-IT trial: ezetimibe added to a statin
• FOURIER trial: evolocumab (American College of Cardiology)
• NCCIH: Red yeast rice
• Cochrane review of omega-3 supplements and heart disease (summary)

Reviewed 1 November 2026. General education, not personal medical advice. Treatment depends on your situation, so talk to your GP or pharmacist.

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