The cholesterol test is a quantitative analysis of the cholesterol levels in a sample of the patient's blood. Total serum cholesterol (TC) is the measurement routinely taken. Doctors sometimes order a complete lipoprotein profile to better evaluate the risk for atherosclerosis (coronary artery disease, or CAD). The full lipoprotein profile also includes measurements of triglyceride levels (a chemical compound that forms 95% of the fats and oils stored in animal or vegetable cells) and lipoproteins (high density and low density). Blood fats also are called "lipids." It is estimated that more than 200 million cholesterol tests are performed each year in the United States.
The type of cholesterol in the blood is as important as the total quantity. Cholesterol is a fatty substance and cannot be dissolved in water. It must combine with a protein molecule called a lipoprotein in order to be transported in the blood. There are five major types of lipoproteins in the human body; they differ in the amount of cholesterol that they carry in comparison to other fats and fatty acids, and in their functions in the body. Lipoproteins are classified, as follows, according to their density:
- Chylomicrons. These are normally found in the blood only after a person has eaten foods containing fats. They contain about 7% cholesterol. Chylomicrons transport fats and cholesterol from the intestine into the liver, then into the bloodstream. They are metabolized in the process of carrying food energy to muscle and fat cells.
- Very low-density lipoproteins (VLDL). These lipoproteins carry mostly triglycerides, but they also contain 16-22% cholesterol. VLDLs are made in the liver and eventually become IDL particles after they have lost their triglyceride content.
- Intermediate-density lipoproteins (IDL). IDLs are short-lived lipoproteins containing about 30% cholesterol that are converted in the liver to low-density lipoproteins (LDLs).
- Low-density lipoproteins (LDL). LDL molecules carry cholesterol from the liver to other body tissues. They contain about 50% cholesterol. Extra LDLs are absorbed by the liver and their cholesterol is excreted into the bile. LDL particles are involved in the formation of plaques (abnormal deposits of cholesterol) in the walls of the coronary arteries. LDL is known as "bad cholesterol."
- High-density lipoproteins (HDL). HDL molecules are made in the intestines and the liver. HDLs are about 50% protein and 19% cholesterol. They help to remove cholesterol from artery walls. Lifestyle changes, including exercising, keeping weight within recommended limits, and giving up smoking can increase the body's levels of HDL cholesterol. HDL is known as "good cholesterol."
- Lipoprotein subclasses. By identifying levels of multiple subclasses of lipid abnormalities, physicians can do a better job of prescribing lipid-lowering therapies, particularly in high-risk patients such as those with type 2 diabetes.
Because of the difference in density and cholesterol content of lipoproteins, two patients with the same total cholesterol level can have very different lipid profiles and different risk for CAD. The critical factor is the level of HDL cholesterol in the blood serum. Some doctors use the ratio of the total cholesterol level to HDL cholesterol when assessing the patient's degree of risk. A low TC/HDL ratio is associated with a lower degree of risk.
The purpose of the TC test is to measure the levels of cholesterol in the patient's blood. The patient's cholesterol also can be fractionated (separated into different portions) in order to determine the TC/HDL ratio. The results help the doctor assess the patient's risk for coronary artery disease (CAD). High LDL levels are associated with increased risk of CAD whereas high HDL levels are associated with relatively lower risk.
In addition, the results of the cholesterol test can assist the doctor in evaluating the patient's metabolism of fat, or in diagnosing inflammation of the pancreas, liver disease, or disorders of the thyroid gland.
The frequency of cholesterol testing depends on the patient's degree of risk for CAD. People with low cholesterol levels may need to be tested once every five years. People with high levels of blood cholesterol should be tested more frequently, according to their doctor's advice. The doctor may recommend a detailed evaluation of the different types of lipids in the patient's blood. It is ideal to check the HDL and triglycerides as well as the cholesterol and LDL. In addition, the National Cholesterol Education Program (NCEP) suggests further evaluation if the patient has any of the symptoms of CAD or if she or he has two or more of the following risk factors for CAD:
- male sex
- high blood pressure
- low HDL levels
- family history of CAD before age 55
The necessity of widespread cholesterol screening is a topic with varying responses. In 2003, a report demonstrated that measuring the cholesterol of everyone at age 50 years was a simple and efficient way to identify those most at risk for heart disease from among the general population.
Patients who are seriously ill or hospitalized for surgery should not be given cholesterol tests because the results will not indicate the patient's normal cholesterol level. Acute illness, high fever, starvation, or recent surgery lowers blood cholesterol levels.
A pharmaceutical corporation announced in the spring of 2004 that it had received an application to patent a device that could use saliva to determine cholesterol levels. If the test becomes available, it could make screening much more convenient and accessible.
The cholesterol test requires a sample of the patient's blood. Fasting before the test is required to get an accurate triglyceride and LDL level. The blood is withdrawn by the usual vacuum tube technique from one of the patient's veins. The blood test takes between three and five minutes.
Patients who are scheduled for a lipid profile test should fast (except for water) for 12-14 hours before the blood sample is drawn. If the patient's cholesterol is to be fractionated, he or she also should avoid alcohol for 24 hours before the test.
Patients also should stop taking any medications that may affect the accuracy of the test results. These include corticosteroids, estrogen or androgens, oral contraceptives, some diuretics, haloperidol, some antibiotics, and niacin. Antilipemics are drugs that lower the concentration of fatty substances in the blood. When these are taken by the patient, blood testing may be done frequently to evaluate the liver function as well as lipids. The patient's doctor will give the patient a list of specific medications to be discontinued before the test.
Aftercare includes routine care of the skin around the needle puncture. Most patients have no after-effects, but some may have a small bruise or swelling. A washcloth soaked in warm water usually relieves discomfort. In addition, the patient should resume taking any prescription medications that were discontinued before the test.
The primary risk to the patient is a mild stinging or burning sensation during the venipuncture, with minor swelling or bruising afterward.
The "normal" values for serum lipids depend on the patient's age, sex, and race. Normal values for people in Western countries were once presumed to be 140-220 mg/dL in adults, although as many as 5% of the population has TC higher than 300 mg/dL. Among Asians, the figures are about 20% lower. As a rule, both TC and LDL levels rise as people get older. However, in 2001, the NCEP released stricter guidelines for LDL and total cholesterol.
Some doctors prefer to speak of "desired" rather than "normal" cholesterol values, on the grounds that "normal" refers to statistically average levels that may still be too high for good health. The NCEP has outlined the levels according to desirable and risk:
- Optimal LDL cholesterol: less than 100 mg/dL and total cholesterol less than 160 mg/dL
- Desirable LDL cholesterol: 100-129 mg/dL; total cholesterol 160-199 mg/dL
- Borderline high risk: LDL cholesterol 130-159 mg/dL; total cholesterol 200-239 mg/dL
- High risk: LDL cholesterol greater than 160 mg/dL; total cholesterol greater than or at 240 mg/dL.
It is possible for blood cholesterol levels to be too low as well as too high.
Abnormally low levels
TC levels less than 160 mg/dL are associated with higher mortality rates from cancer, liver disease, respiratory disorders, and injuries. The connection between unusually low cholesterol and increased mortality is not clear, although some researchers think that the low level is a secondary sign of the underlying disease and not the cause of disease or death.
Low levels of serum cholesterol are also associated with malnutrition or hyperthyroidism. Further diagnostic testing may be necessary in order to locate the cause.
Abnormally high levels
Prior to 1980, hypercholesterolemia (an abnormally high TC level) was defined as any value above the 95th percentile for the population. These figures ranged from 210 mg/dL in persons younger than 20 to more than 280 mg/dL in persons older than 60. It is now known, however, that TC levels over 200 mg/dL are associated with significantly higher risk of CAD. Levels of 280 mg/dL or more are considered elevated. Treatment with diet and medication has proven to successfully lower risk of heart attack and stroke.
Elevated cholesterol levels also may result from hepatitis, blockage of the bile ducts, disorders of lipid metabolism, nephrotic syndrome, inflammation of the pancreas, or hypothyroidism.
Atherosclerosis — A disease of the coronary arteries in which cholesterol is deposited in plaques on the arterial walls. The plaque narrows or blocks blood flow to the heart. Atherosclerosis sometimes is called coronary artery disease, or CAD.
Fractionation — A laboratory test or process in which blood or another fluid is broken down into its components. Fractionation can be used to assess the proportions of the different types of cholesterol in a blood sample.
High-density lipoprotein (HDL) — A type of lipoprotein that protects against coronary artery disease by removing cholesterol deposits from arteries or preventing their formation.
Hypercholesterolemia — The presence of excessively high levels of cholesterol in the blood.
Lipid — Any organic compound that is greasy, insoluble in water, but soluble in alcohol. Fats, waxes, and oils are examples of lipids.
Lipoprotein — A complex molecule that consists of a protein membrane surrounding a core of lipids. Lipoproteins carry cholesterol and other lipids from the digestive tract to the liver and other body tissues. There are five major types of lipoproteins.
Low-density lipoprotein (LDL) — A type of lipoprotein that consists of about 50% cholesterol and is associated with an increased risk of coronary artery disease.
Plaque — An abnormal deposit of hardened cholesterol on the wall of an artery.
Triglyceride — A chemical compound that forms about 95% of the fats and oils stored in animal and vegetable cells. Triglyceride levels sometimes are measured as well as cholesterol when a patient is screened for heart disease.
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"Cholesterol Test at Age 50 Spots Those in Greatest Danger." Heart Disease Weekly July 27, 2003: 3.
"Company Wins U.S. Patent for Saliva Cholesterol Test." Heart Disease Weekly May 23, 2004: 66.
"Study Shows Expanded Cholesterol Test Sparked Use of Lipid-lowering Therapy." Heart Disease Weekly July 13, 2003: 20.