Case study - Hypercholesterolaemia

Dr Harry Brown demonstrates the importance of making further investigations into high cholesterol.

It is important to carry out a full cardiovascular check on patients
It is important to carry out a full cardiovascular check on patients

Mrs S was a 44-year-old business executive and an infrequent attendee at the surgery.

However, when she did come, she was keen to ask searching questions. She was otherwise well, a non-smoker, worked out in the gym three times a week and was not on regular medication.

She visited the surgery because her father had recently died from a heart attack and she had decided she wanted a cholesterol check. Her brother had a cholesterol check with another practice and his was normal and she felt she should do the same. She disclosed that there was no family history of a lipid disorder.

Full cardiovascular check
I suggested that she make an appointment to see the nurse where she could have a full cardiovascular check of her BP, BMI and cholesterol.

She also mentioned that despite her active lifestyle, she was struggling to lose weight and actually thought she was gaining weight. She wanted advice and asked about diet pills. After discussing the options, she decided to leave medication and concentrate on improving her diet.

A couple of weeks later, on a routine perusal of blood test results, I noticed Mrs S's cholesterol result was 9.7mmol/L.

This surprised me as her BMI was only 28 and her reported alcohol intake was minimal. After a telephone discussion about these results, an appointment was arranged for the next day.

Mrs S had done some internet research on high cholesterol and had lots of questions. She was concerned she would have a heart attack but I reassured her that this was unlikely as she had no symptoms or signs of cardiovascular disease.

I explained it was highly likely that her lipid disorder was treatable. I confirmed again that there was no family history of a lipid disorder and tried to answer her many questions as best as I could.

Further investigations
Mrs S was concerned about the cause of her high cholesterol so I arranged for a full fasting lipid profile plus a number of screening blood tests to exclude causes of secondary hyperlipidaemia.

Two days later, her results came though and her abnormal lipid profile was consistent with the original result but there was one other significant abnormal result - she was hypothyroid.

Her TSH was 24mIU/L and her T4 was 4.5pmol/L. This probably explained her weight gain and her abnormal lipid profile. We discussed this result and because she was about to embark on long-term therapy, it seemed sensible to repeat the tests just to make sure that no error had crept in. The repeat result was exactly the same.

She was started on replacement levothyroxine and eventually her TSH and T4 normalised when her levothyroxine dose adapted to a satisfactory maintenance dose. Her lipid profile subsequently normalised and she lost 3kg in weight and felt as if she had more energy.

She was delighted with the final outcome. She remains well and currently has no abnormal biochemical indices.

  • Dr Brown is a GP in Leeds

Potential causes of secondary hyperlipidaemia

  • Hypothyroidism
  • Diabetes
  • Renal impairment
  • Hepatic impairment
  • Drugs
  • Excess alcohol intake


Learning points
  • If an abnormal lipid profile is found, always consider a secondary cause.
  • Always take a patient's concerns seriously.
  • If a patient brings in printed information (website, newspaper etc) try to read it and appraise it.
  • Ask about family history of lipid disorders.

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