Cardiologist Dr. Paul D. Thompson, MD, explains why high cholesterol usually goes unnoticed unless it is measured or causes heart problems. He describes a rare tendon problem in young people, how plaque can suddenly block a coronary artery, and what exertional chest tightness feels like.
High Cholesterol Without Symptoms: Artery Deposits, Heart Attack, and Angina
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- Why high cholesterol is called silent
- How high and for how long
- Achilles tendonitis in young people
- Where cholesterol deposits in arteries
- Stiff arteries and the crack in the plaque
- Chest discomfort with exertion
- Full Transcript
Why high cholesterol is called silent
A high cholesterol level by itself does not cause symptoms. Asked by Dr. Anton Titov, MD, whether a person would notice high cholesterol, cardiologist Dr. Paul D. Thompson, MD, compares it with hypertension, which is often described as a silent killer. He applies the same description to cholesterol.
In his explanation, the cholesterol level simply sits there while cholesterol is deposited in the arteries over time. A person does not know it is there unless it is measured, and may not learn that it is high until a heart attack or chest discomfort occurs.
How high and for how long
Cumulative exposure is the concept Dr. Thompson uses to describe cholesterol risk. He borrows the idea of pack years from cigarette smoking, where doctors ask how many packs a person smoked and for how many years.
He says the same concept applies to cholesterol. What matters is how high the cholesterol is, measured in milligrams or millimoles, and how long that level has existed in the body.
Achilles tendonitis in young people
Achilles tendonitis is the exception Dr. Thompson adds to his statement that cholesterol causes no symptoms. He says children born with very high cholesterol levels can develop Achilles tendonitis in their teens, especially if they are very active.
His explanation is that cholesterol deposits at places of trauma and turbulence. Every step puts a small stretch on the Achilles tendon, and he illustrates this by briefly singing a line from a well-known song about every step you take. He stresses that this kind of tendonitis is quite rare and occurs only in young people with very high cholesterol levels.
Where cholesterol deposits in arteries
Turbulence and bending explain where cholesterol tends to build up, according to Dr. Thompson. The heart arteries are called coronary arteries because they crown the heart. Because they are attached to the heart, he says, they twist and turn with every heartbeat, and doctors think this flexing is one reason cholesterol deposits there.
He names other common sites. One is the S-shaped curve of the artery going up to the neck, called the carotid siphon. Another is the place where the abdominal aorta branches into the two iliac arteries, where there is turbulence. The femoral arteries in the groin also collect a lot of cholesterol, which he links to frequent bending.
Stiff arteries and the crack in the plaque
Sudden blockage is the first danger Dr. Thompson describes. Early cholesterol deposits do not narrow the artery enough to cause symptoms, but they make the artery wall stiff. He compares this to a rubber hose left out in the sun: it stiffens, and bending it back and forth can crack it.
He explains that atherosclerosis means hardening of the arteries. A stiff coronary artery that keeps twisting with the heart can develop a crack in the plaque, which he likens to a cut on the skin. There is some bleeding, a blood clot forms, and the open artery can suddenly become blocked so that no blood reaches the heart. He says this can cause a heart attack or, worse, sudden cardiac death.
Chest discomfort with exertion
Angina is another type of symptom Dr. Thompson describes, caused by narrowing of the arteries over time. If an artery has become smaller and a person exerts themselves with something vigorous, such as climbing stairs, going for a run, or having sex, they can feel discomfort in the chest.
He deliberately says discomfort rather than pain, because it is often not a pain. He mentions the fist sign, named after the Boston cardiologist Samuel Levine, and explains that angina comes from the Latin word for choking. In his description, it is a feeling of tightness in the chest during exertion.
Full Transcript
Dr. Anton Titov, MD: Does high cholesterol actually cause any symptoms I'd notice?
Dr. Paul D. Thompson, MD: A high cholesterol level by itself does not cause any symptoms. We always talk about hypertension as being a silent killer. The same thing applies to cholesterol levels.
Dr. Paul D. Thompson, MD: The cholesterol level just sits there, and over time it deposits cholesterol in your arteries. When we talk about the risk of cigarette smoking, we talk about the pack years of cholesterol. How many packs did you smoke for how many years?
Dr. Paul D. Thompson, MD: The same concept applies to cholesterol. How high is your cholesterol, and how long did it exist in your system? In other words, the milligrams or the millimoles of cholesterol and how long they exist in your system.
Dr. Paul D. Thompson, MD: Now, the cholesterol level itself does not cause any symptoms. I am going to back off on that a little bit. Kids that are born with very high cholesterol levels often can get Achilles tendonitis in their teens, especially if they are very active.
Dr. Paul D. Thompson, MD: Now, why is that? Cholesterol deposits in the body at places of trauma and turbulence. Every step you take, like that song, 'Every step you take, I will be watching you' - sorry for the voice - every step you take puts a little stretch on your Achilles tendon.
Dr. Paul D. Thompson, MD: So if you have very high cholesterol levels, you can deposit it in your Achilles tendon, and some young people will get Achilles tendonitis. But in general, cholesterol is just a silent killer. You do not know it is there unless you get it measured.
Dr. Paul D. Thompson, MD: You do not know it is high until you wind up with a heart attack or chest discomfort. So let us talk about chest discomfort and heart attacks for just a minute. What cholesterol does is it deposits in the heart arteries.
Dr. Paul D. Thompson, MD: A minute ago I spoke about how where you deposit cholesterol depends on what we call turbulence. And we think that one of the reasons you deposit cholesterol in the heart arteries... These arteries that sit on your heart are called the coronary arteries because they look like a crown. They crown the heart.
Dr. Paul D. Thompson, MD: We think people put cholesterol in the coronary arteries because every time your heart beats, those coronary arteries have to twist and turn, because they are attached to the heart. They go along with the ride. So it is like there is a flexing of those coronary arteries.
Dr. Paul D. Thompson, MD: You put cholesterol at places of trauma, where arteries bend, where arteries are injured. For example, one of the places you put a lot of cholesterol is in this curve that goes up to your neck. It looks like an S, and we call it the carotid siphon because it looks like an S; it looks like a siphon.
Dr. Paul D. Thompson, MD: You also put cholesterol in your abdominal aorta, where your abdominal aorta branches from the big aorta into the two iliac arteries. Why? Because there is turbulence at that branch point.
Dr. Paul D. Thompson, MD: You put a lot of cholesterol in your groin arteries, the femoral arteries in the groin. Why? Because you are often bent, and that bending causes turbulence.
Dr. Paul D. Thompson, MD: So except for things like Achilles tendinitis, which is quite rare and only happens in kids who have very high cholesterol levels, cholesterol, like hypertension, is just a silent killer. It does not do anything until it gives you your heart attack or your sudden cardiac death. Now I am going to pause just for a minute and say that I started to talk about the signs and symptoms of cholesterol deposits in arteries.
Dr. Paul D. Thompson, MD: So what does it do? First of all, deposits of cholesterol in the arteries can cause sudden death from a heart attack, and here is what happens. Suppose you have got some cholesterol depositing in that artery.
Dr. Paul D. Thompson, MD: When it first starts to deposit, it does not make the artery narrow enough to cause you symptoms. All you have is some deposits of cholesterol in the wall of the artery. That makes the artery stiff, almost like a rubber hose that you have left out in the sun.
Dr. Paul D. Thompson, MD: If you leave a rubber hose out in the sun, it gets stiff. And then if you bend it back and forth, you can get a crack in the hose. The same thing happens with the coronary arteries.
Dr. Paul D. Thompson, MD: If you are depositing cholesterol in those heart arteries, they get stiff. We call it athero, which means artery, sclerosis, which means hardening, like sclerosing a vein or something. Atherosclerosis, hardening of the arteries.
Dr. Paul D. Thompson, MD: Remember those coronary arteries: we call them coronaries because they crown the heart, and every time the heart beats, they have to twist and turn along with the heart. That twisting and turning of that stiff artery is just like twisting and turning your rubber hose. You can get a crack in the coronary plaque, the so-called crack in the plaque, and that crack in the plaque is like a cut on your skin.
Dr. Paul D. Thompson, MD: You bleed a little bit, and then you form a blood clot. If you form a blood clot in your coronary artery, you go from having this open artery to nothing all of a sudden. So there is no blood getting to your heart.
Dr. Paul D. Thompson, MD: That can cause a heart attack, and worse, it can also cause sudden cardiac death. Now, there is another type of symptom that narrowing of the arteries has. If your artery gets smaller over time, then when you exert yourself and you do something vigorous, have sex, climb the stairs, go for a run, you can get a discomfort in your chest.
Dr. Paul D. Thompson, MD: Why did I use the term discomfort and not pain? Because it is often not a pain. It is a discomfort.
Dr. Paul D. Thompson, MD: In fact, there is something called the fist sign, named after the famous Boston cardiologist Samuel Levine. He described the fist sign because so many patients would come in and say, "I have this feeling in my chest when I exert myself." That is called angina.
Dr. Paul D. Thompson, MD: Angina in Latin means choking, and it is a bit of a tightness feeling. Not necessarily a pain, but a tightness in your chest when you exert yourself. So what do you get out of cholesterol deposits in your coronary arteries?
Dr. Paul D. Thompson, MD: You can get a heart attack, a sudden blockage. You can get sudden death, which often happens with the blockage. And then you can get that narrowing over time, which gives you the chest discomfort called angina, or choking.