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Hypercholesterolemia
Classification and external resources
Cholesterol
ICD-10 E78.0
ICD-9 272.0
DiseasesDB 6226
eMedicine med/1073 
MeSH D006937

Hypercholesterolemia (literally: high blood cholesterol) is the presence of high levels of cholesterol in the blood [1]. Cholesterol is a Lipid found in the Cell membranes and transported in the Blood plasma of all Animals It is an essential component of mammalian The International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) provides codes to classify Diseases The International Statistical Classification of Diseases and Related Health Problems 10th Revision ( ICD -10) is a coding of diseases and signs symptoms abnormal findings E00-E35 - Endocrine diseases (E00-E07 Thyroid gland / Thyroid hormone ( Congenital iodine-deficiency syndrome ( The International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) provides codes to classify Diseases The following is a list of codes for International Statistical Classification of Diseases and Related Health Problems. The Diseases Database is a free Website that provides information about the relationships between medical conditions Symptoms, and Medications. eMedicine is an online clinical medical knowledge base that was founded in 1996 by Scott Plantz and Richard Lavely two medical doctors Medical Subject Headings ( MeSH) is a huge Controlled vocabulary (or metadata system for the purpose of indexing journal articles and books Cholesterol is a Lipid found in the Cell membranes and transported in the Blood plasma of all Animals It is an essential component of mammalian It is not a disease but a metabolic derangement that can be secondary to many diseases and can contribute to many forms of disease, most notably cardiovascular disease. A disease is an abnormal condition of an organism that impairs bodily functions and can be deadly Metabolism is the set of Chemical reactions that occur in living Organisms in order to maintain Life. Cardiovascular disease or cardiovascular diseases refers to the class of diseases that involve the Heart or Blood vessels ( arteries and It is closely related to the terms "hyperlipidemia" (elevated levels of lipids) and "hyperlipoproteinemia" (elevated levels of lipoproteins). Hyperlipidemia, hyperlipoproteinemia or dyslipidemia is the presence of raised or abnormal levels of Lipids and/or Lipoproteins in the Lipids are broadly defined as any fat- Soluble ( lipophilic) naturally-occurring Molecule, such as fats oils waxes cholesterol sterols fat-soluble Hyperlipidemia, hyperlipoproteinemia or dyslipidemia is the presence of raised or abnormal levels of Lipids and/or Lipoproteins in the A lipoprotein is a biochemical assembly that contains both Proteins and Lipids The lipids or their derivatives may be covalently or non-covalently bound Familial hypercholesterolemia is a rare genetic disorder that can occur in families, wherein those affected cannot properly metabolise cholesterol. Familial hypercholesterolemia (abbreviated FH, also spelled familial hypercholesterolaemia) is a Genetic disorder characterized by high cholesterol A genetic disorder is a condition caused by abnormalities in Genes or Chromosomes While some diseases such as Cancer, are due to genetic abnormalities acquired

Contents

Signs and symptoms

Elevated cholesterol does not lead to specific symptoms unless it has been longstanding. Cholesterol is a Lipid found in the Cell membranes and transported in the Blood plasma of all Animals It is an essential component of mammalian Some types of hypercholesterolemia lead to specific physical findings: xanthoma (thickening of tendons due to accumulation of cholesterol), xanthelasma palpabrum (yellowish patches around the eyelids) and arcus senilis (white discoloration of the peripheral cornea). A xanthoma (or xanthomata or xanthomatosis) (from Greek xanthos, ξανθος, "yellow" is a deposition of yellowish Cholesterol A tendon (or sinew) is a tough band of Fibrous connective tissue that usually connects Muscle to Bone and is capable of withstanding tension Cholesterol is a Lipid found in the Cell membranes and transported in the Blood plasma of all Animals It is an essential component of mammalian Xanthelasma (or xanthelasma palpebrarum) is a sharply demarcated yellowish collection of Cholesterol underneath the skin usually on or around the Eyelids Arcus senilis (or Arcus senilis corneae) is a white or gray opaque ring in the corneal margin (peripheral corneal opacity present at birth or appearing later in life and becoming

Longstanding elevated hypercholesterolemia leads to accelerated atherosclerosis; this can express itself in a number of cardiovascular diseases:[2]

Diagnosis

When measuring cholesterol, it is important to measure its subfractions before drawing a conclusion on the cause of the problem. Atherosclerosis is a Disease affecting arterial Blood vessels It is a chronic inflammatory response in the walls of arteries in large part due to the accumulation Cardiovascular disease or cardiovascular diseases refers to the class of diseases that involve the Heart or Blood vessels ( arteries and Angina pectoris, commonly known as angina, is severe Chest pain due to Ischemia (a lack of blood and hence Oxygen supply of the heart Myocardial infarction ( MI or AMI for acute myocardial infarction) also known as a heart attack, occurs when the blood supply A transient ischemic attack ( TIA, often colloquially referred to as “ mini stroke ” is caused by the changes in the blood supply to a particular area of the A stroke is the rapidly developing loss of brain functions due to a disturbance in the blood vessels supplying blood to the brain Peripheral vascular disease (PVD also known as peripheral artery disease (PAD or peripheral artery occlusive disease (PAOD is a collator for all Diseases Cholesterol is a Lipid found in the Cell membranes and transported in the Blood plasma of all Animals It is an essential component of mammalian The subfractions are LDL, HDL and VLDL. Low-density lipoprotein ( LDL) is a type of Lipoprotein that transports Cholesterol and Triglycerides from the Liver to peripheral High-density lipoproteins ( HDL) is one of the 5 major groups of Lipoproteins ( Chylomicrons, VLDL, IDL, LDL, HDL In the past, LDL and VLDL levels were rarely measured directly due to cost concerns. VLDL levels are reflected in the levels of triglycerides (generally about 45% of triglycerides is composed of VLDL). (more properly known as, TAG or triacylglyceride) is Glyceride in which the Glycerol is Esterified with three Fatty acids It is the LDL was usually estimated as a calculated value from the other fractions (total cholesterol minus HDL and VLDL); this method is called the Friedewald calculation; specifically: LDL ~= Total Cholesterol - HDL - (0. 2 x Triglycerides).

Less expensive (and less accurate) laboratory methods and the Friedewald calculation have long been utilized because of the complexity, labor and expense of the electrophoretic methods developed in the 1970s to identify the different lipoprotein particles which transport cholesterol in the blood. Electrophoresis is the most well-known electrokinetic phenomenon. A lipoprotein is a biochemical assembly that contains both Proteins and Lipids The lipids or their derivatives may be covalently or non-covalently bound In 1980, the original methods, developed by research work in the mid-1970s cost about $5,000, in US 1980 dollars, per blood sample/person.

With time, more advanced laboratory analyses have been developed which do measure LDL and VLDL particle sizes and levels, and at far lower cost. These have partly been developed and become more popular as a result of the increasing clinical trial evidence that intentionally changing cholesterol transport patterns, including to certain abnormal values compared to most adults, often has a dramatic effect on reducing, even partially reversing, the atherosclerotic process. Atherosclerosis is a Disease affecting arterial Blood vessels It is a chronic inflammatory response in the walls of arteries in large part due to the accumulation With ongoing research and advances in laboratory methods, the prices for more sophisticated analyses have markedly decreased, to less than $100, US 2004, by some labs, and with simultaneous increases in the accuracy of measurement for some of the methods.

Screening

Screening for a disease refers to testing for a disease, such as hypercholesterolemia, in patients who have no signs or symptoms of the disease. Screening, in medicine is a strategy used in a Population to detect a Disease in individuals without signs or Symptoms of that disease

In patients without any other risk factors, moderate hypercholesterolemia is often not treated. According to Framingham Heart Study, people with an age greater than 50 years have no increased overall mortality with either high or low serum cholesterol levels. The Framingham Heart Study is a cardiovascular study based in Framingham Massachusetts. There is, however, a correlation between falling cholesterol levels over the first 14 years and mortality over the following 18 years (11% overall and 14% CVD death rate increase per 1 mg/dL per year drop in cholesterol levels). This, however, does not mean that a decrease in serum levels is dangerous, as there has not yet been a recorded heart attack in the study in a person with a total cholesterol below 150 mg/dL.

The U.S. Preventive Services Task Force (USPSTF) has evaluated screening for hypercholesterolemia [3] [4].

Classification

Main article: hyperlipidemia

Fredrickson classification

Classically, hypercholesterolemia was categorized by lipoprotein electrophoresis and the Fredrickson classification. Hyperlipidemia, hyperlipoproteinemia or dyslipidemia is the presence of raised or abnormal levels of Lipids and/or Lipoproteins in the A lipoprotein is a biochemical assembly that contains both Proteins and Lipids The lipids or their derivatives may be covalently or non-covalently bound Electrophoresis is the most well-known electrokinetic phenomenon. Hyperlipidemia, hyperlipoproteinemia or dyslipidemia is the presence of raised or abnormal levels of Lipids and/or Lipoproteins in the Newer methods, such as "lipoprotein subclass analysis" have offered significant improvements in understanding the connection with atherosclerosis progression and clinical consequences. Atherosclerosis is a Disease affecting arterial Blood vessels It is a chronic inflammatory response in the walls of arteries in large part due to the accumulation

If the hypercholesterolemia is hereditary (familial hypercholesterolemia), there is more often a family history of premature, earlier onset atherosclerosis, as well as familial occurrence of the signs mentioned above. Familial hypercholesterolemia (abbreviated FH, also spelled familial hypercholesterolaemia) is a Genetic disorder characterized by high cholesterol In Medicine, a family history consists of information about disorders that a patient's direct blood relatives have suffered from Atherosclerosis is a Disease affecting arterial Blood vessels It is a chronic inflammatory response in the walls of arteries in large part due to the accumulation

Secondary causes

There are a number of secondary causes for high cholesterol:

All three of these activities done together can have a positive effect on one's blood cholesterol level.

Dietary influence

While part of the circulating cholesterol originates from diet, and restricting cholesterol intake may reduce blood cholesterol levels, there are various other links between the dietary pattern and cholesterol levels. The American Heart Association also compiles a list of the acceptable/unacceptable foods for those who are diagnosed with hypercholesterolemia.

Carbohydrates

Evidence is accumulating that eating more carbohydrates - especially simpler, more refined carbohydrates - increases levels of triglycerides in the blood, lowers HDL, and may shift the LDL particle distribution pattern into unhealthy atherogenic patterns. Carbohydrates (from ' Hydrates of Carbon ' or saccharides ( Greek σάκχαρον meaning " Sugar " are the most (more properly known as, TAG or triacylglyceride) is Glyceride in which the Glycerol is Esterified with three Fatty acids It is the In Pathology, an atheroma (plural atheromata is an accumulation and swelling (-oma in Artery walls that is made up of cells (mostly Macrophage cells

Trans fats

An increasing number of researchers are suggesting that a major dietary risk factor for cardiovascular diseases is trans fatty acids, and in the US the FDA has revised food labeling requirements to include listing trans fat quantities. Trans fat is the common name for a type of Unsaturated fat with trans - isomer Fatty acid (s

Treatment

Clinical Evidence has summarized treatment for both primary prevention [5] and secondary prevention [6]. Two factors to consider when choosing therapy are the patient's risk of coronary disease and their lipoprotein pattern.

Risk of coronary disease. To calculate the benefit of treatment, there are two online calculators that can estimate baseline risk [7] [8]. Combining the baseline risk with the relative risk reduction of a treatment can lead to the absolute risk reduction of number needed to treat. The relative risk reduction is a measure used in Epidemiology. The number needed to treat (NNT is an epidemiological measure used in assessing the effectiveness of a health-care intervention typically a treatment with Medication For example, one of the calculators projects that a patient had a 10% risk of coronary disease over ten years. As noted below, the relative risk reduction of a statin is 30%. The relative risk reduction is a measure used in Epidemiology. The statins (or HMG-CoA reductase inhibitors) form a class of hypolipidemic drugs used to lower Cholesterol levels in people with or at risk of Cardiovascular Thus, after 4-7 years of treatment with a statin, a patient's risk will drop to 7%. The statins (or HMG-CoA reductase inhibitors) form a class of hypolipidemic drugs used to lower Cholesterol levels in people with or at risk of Cardiovascular This equates to an absolute risk reduction of 3%, or a number needed to treat of 33. The number needed to treat (NNT is an epidemiological measure used in assessing the effectiveness of a health-care intervention typically a treatment with Medication Thirty three such patients must be treated for 4-7 years for one to benefit.
Lipoprotein patterns. (See hyperlipoproteinemia for details) The treatment depends on the type of hypercholesterolemia. Hyperlipidemia, hyperlipoproteinemia or dyslipidemia is the presence of raised or abnormal levels of Lipids and/or Lipoproteins in the Clinical trials, starting in the 1970s, have repeatedly and increasingly found that normal cholesterol values do not necessarily reflect healthy cholesterol values. Cholesterol is a Lipid found in the Cell membranes and transported in the Blood plasma of all Animals It is an essential component of mammalian Cholesterol is a Lipid found in the Cell membranes and transported in the Blood plasma of all Animals It is an essential component of mammalian This has increasingly lead to the newer concept of dyslipidemia, despite normo-cholesterolemia. Dyslipidemia is a disruption in the amount of Lipids in the blood Thus there has been increasing recognition of the importance of "lipoprotein subclass analysis" as an important approach to better understand and change the connection between cholesterol transport and atherosclerosis progression. Atherosclerosis is a Disease affecting arterial Blood vessels It is a chronic inflammatory response in the walls of arteries in large part due to the accumulation Fredrickson Types IIa and IIb can be treated with diet, statins (most prominently rosuvastatin, atorvastatin, simvastatin, or pravastatin), cholesterol absorption inhibitors (ezetimibe), fibrates (gemfibrozil, bezafibrate, fenofibrate or ciprofibrate), vitamin B3 (niacin), bile acid sequestrants (colestipol, cholestyramine), LDL apheresis and in hereditary severe cases liver transplantation. Hyperlipidemia, hyperlipoproteinemia or dyslipidemia is the presence of raised or abnormal levels of Lipids and/or Lipoproteins in the Dieting is the practice of ingesting food in a regulated fashion to achieve or maintain a controlled weight The statins (or HMG-CoA reductase inhibitors) form a class of hypolipidemic drugs used to lower Cholesterol levels in people with or at risk of Cardiovascular Rosuvastatin is a member of the drug class of Statins used to treat Hypercholesterolemia and related conditions and to prevent Cardiovascular disease Atorvastatin ( INN) (əˌtɔrvəˈstætən (marketed under the name Lipitor, Lipidra Aztor Torvatin Sortis Torvast Torvacard Totalip Tulip Xarator Simvastatin ( INN) (ˈsɪmvəstætɨn (marketed under the trade names Zocor, Simvastatin Simlup Simcard and others is a hypolipidemic drug belonging Pravastatin (marketed as Pravachol or Selektine) is a member of the drug class of Statins used for lowering Cholesterol and preventing Cardiovascular Ezetimibe (ɛˈzɛtəmɪb is an anti-hyperlipidemic medication which is used to lower cholesterol levels In Pharmacology, the fibrates are a class of amphipathic Carboxylic acids They are used for a range of metabolic disorders mainly Hypercholesterolemia Gemfibrozil is the Generic name for an oral drug used to lower Lipid levels Bezafibrate (Bezalip and various other brand names is a Fibrate Drug used for the treatment of Hyperlipidaemia. Fenofibrate is a drug of the Fibrate class Fenofibrate was discovered by Groupe Fournier SA, before it was acquired by Solvay Pharmaceutical in 2005 Ciprofibrate is a Fibrate.Cristaline powder white or almost white Niacin, also known as vitamin B3, is a water-soluble vitamin which prevents the deficiency disease Pellagra. The bile acid sequestrants are a group of medications used for binding certain components of Bile in the gastrointestinal tract. Colestipol is a Bile acid sequestrant. Cholestyramine or colestyramine ( Questran Questran Light, Cholybar) is a Bile acid sequestrant, which binds Bile in the Gastrointestinal In Medicine, LDL apheresis is a form of Apheresis, resembling Dialysis, to eliminate the Cholesterol -containing particle Low-density lipoprotein Liver transplantation or hepatic transplantation is the replacement of a diseased Liver with a healthy liver Allograft.

Multiple clinical trials, each, by design, examining only one of multiple relevant issues, have increasingly examined the connection between these issues and atherosclerosis clinical consequences. Atherosclerosis is a Disease affecting arterial Blood vessels It is a chronic inflammatory response in the walls of arteries in large part due to the accumulation Some of the better recent randomized human outcome trials include ASTEROID, ASCOT-LLA, REVERSAL, PROVE-IT, CARDS, Heart Protection Study, HOPE, PROGRESS, COPERNICUS, and especially a newer research approach utilizing a synthetically produced and IV administered human HDL, the Apo A-I Milano Trial. The ASTEROID trial was a Clinical trial published in 2006 that shows the effects of Statins (drugs that inhibit the enzyme HMG-CoA reductase) The Heart Protection Study was a large Randomized controlled trial run by the Clinical Trial Service Unit, and fundedby the Medical Research Council High-density lipoproteins ( HDL) is one of the 5 major groups of Lipoproteins ( Chylomicrons, VLDL, IDL, LDL, HDL

Diet

On the other hand, and though less dramatic than the many cardiovascular procedures, some people, especially with newer and more sophisticated information, are changing their eating and especially food supplement patterns, many of the supplements still being prescription agents. Though generally not aware of the internal changes in their cholesterol transport patterns, recent trials have demonstrated increasing success with some of these strategies; see the LDL, HDL and IVUS sections. Cholesterol is a Lipid found in the Cell membranes and transported in the Blood plasma of all Animals It is an essential component of mammalian Low-density lipoprotein ( LDL) is a type of Lipoprotein that transports Cholesterol and Triglycerides from the Liver to peripheral High-density lipoproteins ( HDL) is one of the 5 major groups of Lipoproteins ( Chylomicrons, VLDL, IDL, LDL, HDL Intravascular ultrasound ( IVUS) is a Medical imaging methodology using a specially designed Catheter with a miniaturized Ultrasound probe attached

Dietary changes can potentially be very strong. [9]

Medications

Many primary physicians and heart specialists will initially prescribe medication in combination with diet and exercise. According to various resources, statins are the most commonly used and effective forms of medication for the treatment of high cholesterol. The statins (or HMG-CoA reductase inhibitors) form a class of hypolipidemic drugs used to lower Cholesterol levels in people with or at risk of Cardiovascular The U.S. Preventive Services Task Force (USPSTF) estimated that after 5 to 7 years of treatment, the relative risk reduction by statins on coronary heart disease events is decreased by approximately 30% [3] [4]. The relative risk reduction is a measure used in Epidemiology. The statins (or HMG-CoA reductase inhibitors) form a class of hypolipidemic drugs used to lower Cholesterol levels in people with or at risk of Cardiovascular More recently, a meta-analysis reported an almost identical relative risk reduction of 29. In Statistics, a meta-analysis combines the results of several studies that address a set of related research hypotheses The relative risk reduction is a measure used in Epidemiology. 2% in low risk patients treated for 4. 3 years [10]. A relative risk reduction of 19% in coronary mortality was found in a meta-analysis of patients at all levels of risk. The relative risk reduction is a measure used in Epidemiology. In Statistics, a meta-analysis combines the results of several studies that address a set of related research hypotheses [11]

Clinical practice guidelines

Various clinical practice guidelines have addressed the treatment of hypercholesterolemia. The American College of Physicians has addressed hypercholesterolemia in patients with diabetes [12]. The American College of Physicians (ACP is a national organization of doctors of Internal medicine (internists physicians who specialize in the prevention detection and treatment Diabetes mellitus (ˌdaɪəˈbiːtiːz or /ˌdaɪəˈbiːtəs/ /məˈlaɪtəs/ or /ˈmɛlətəs/ often referred to simply as diabetes ( Ancient Greek: grc Their recommendations are:

The National Cholesterol Education Program revised their guidelines[14]; however, their 2004 revisions have been criticized for use of nonrandomized, observational data. The National Cholesterol Education Program is a program managed by the National Heart Lung and Blood Institute, a division of the National Institutes of Health [15]

Alternative medicine

A survey released in May 2004 by the National Center for Complementary and Alternative Medicine focused on who used complementary and alternative medicine (CAM), what was used, and why it was used in the United States by adults age 18 years and over during 2002. The term alternative medicine, as used in the modern western world encompasses any healing practice "that does not fall within the realm of conventional Medicine. According to this survey, CAM was used to treat cholesterol by 1. 1% of U. S. adults who used CAM during 2002 ([1] table 3 on page 9). Consistent with previous studies, this study found that the majority of individuals (i. e. , 54. 9%) used CAM in conjunction with conventional medicine (page 6). Medicine is the art and science of healing It encompasses a range of Health care practices evolved to maintain and restore Human Health by the

References

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  2. ^ Grundy SM, Balady GJ, Criqui MH, et al (1998). "Primary prevention of coronary heart disease: guidance from Framingham: a statement for healthcare professionals from the AHA Task Force on Risk Reduction. American Heart Association". Circulation 97 (18): 1876–87. PMID 9603549.  
  3. ^ a b Pignone M, Phillips C, Atkins D, Teutsch S, Mulrow C, Lohr K (2001). "Screening and treating adults for lipid disorders". Am J Prev Med 20 (3 Suppl): 77-89. doi:10.1016/S0749-3797(01)00255-0. A digital object identifier ( DOI) is a permanent identifier given to an Electronic document. PMID 11306236.  
  4. ^ a b U. S. Preventive Services Task Force. Screening for Lipid Disorders: Recommendations and Rationale. Retrieved on Feb 26, 2007.
  5. ^ Pignone M. "Primary prevention: dyslipidaemia". Clin Evid: 142-50. PMID 16620402.  
  6. ^ Gami A. "Secondary prevention of ischaemic cardiac events". Clin Evid: 195-228. PMID 16973010.  
  7. ^ Pignone MP; Sheridan SL. med-decisions.com. Retrieved on Feb 26, 2007.
  8. ^ National Cholesterol Education Program. 10-year CVD Risk Calculator (Risk Assessment Tool for Estimating 10-year Risk of Developing Hard CHD (Myocardial Infarction and Coronary Death) Version). Retrieved on Feb 26, 2007.
  9. ^ McMurry MP, Cerqueira MT, Connor SL, Connor WE (1991). "Changes in lipid and lipoprotein levels and body weight in Tarahumara Indians after consumption of an affluent diet". N. Engl. J. Med. 325 (24): 1704-8. PMID 1944471.  
  10. ^ Thavendiranathan P, Bagai A, Brookhart M, Choudhry N (2006). "Primary prevention of cardiovascular diseases with statin therapy: a meta-analysis of randomized controlled trials". Arch Intern Med 166 (21): 2307-13. doi:10.1001/archinte.166.21.2307. A digital object identifier ( DOI) is a permanent identifier given to an Electronic document. PMID 17130382.  
  11. ^ Baigent C, Keech A, Kearney PM, et al (2005). "Efficacy and safety of cholesterol-lowering treatment: prospective meta-analysis of data from 90,056 participants in 14 randomised trials of statins". Lancet 366 (9493): 1267-78. doi:10.1016/S0140-6736(05)67394-1. A digital object identifier ( DOI) is a permanent identifier given to an Electronic document. PMID 16214597.  
  12. ^ Snow V, Aronson M, Hornbake E, Mottur-Pilson C, Weiss K (2004). "Lipid control in the management of type 2 diabetes mellitus: a clinical practice guideline from the American College of Physicians". Ann Intern Med 140 (8): 644-9. PMID 15096336.  
  13. ^ Vijan S, Hayward RA (2004). "Pharmacologic lipid-lowering therapy in type 2 diabetes mellitus: background paper for the American College of Physicians". Ann. Intern. Med. 140 (8): 650-8. PMID 15096337.  
  14. ^ Grundy SM, Cleeman JI, Merz CN, Brewer HB, Clark LT, Hunninghake DB, Pasternak RC, Smith SC, Stone NJ (2004). "Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III Guidelines". J. Am. Coll. Cardiol. 44 (3): 720-32. doi:10.1016/j.jacc.2004.07.001. A digital object identifier ( DOI) is a permanent identifier given to an Electronic document. PMID 15358046.  
  15. ^ Hayward RA, Hofer TP, Vijan S (2006). "Narrative review: lack of evidence for recommended low-density lipoprotein treatment targets: a solvable problem". Ann. Intern. Med. 145 (7): 520-30. PMID 17015870.  

See also

External links

Familial hypercholesterolemia (abbreviated FH, also spelled familial hypercholesterolaemia) is a Genetic disorder characterized by high cholesterol

Dictionary

hypercholesterolemia

-noun

  1. (medicine) an excess of cholesterol in the blood
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