How to Manage Cholesterol Levels to Prevent Stroke in Singapore

Cholesterol is a waxy, fat-like substance that is both made by the liver and obtained from your diet. While cholesterol is essential for various processes in the body such as the synthesis of cell membranes, hormones and vitamin D, excessive levels of cholesterol in the blood may have negative effects on your health. These effects include higher risk of heart diseases and stroke.

According to the Ministry of Health (MOH) Singapore, the prevalence of hyperlipidemia, also known as an elevated level of lipids in your blood, among adults aged 18 to 69 years, has increased from 35.5% in 2017 to 39.1% in 2021-2022. This underscores the urgent need to adopt a proactive approach to manage cholesterol levels in order to prevent strokes.

Understanding Cholesterol: Types and Measurement

Types of cholesterol and their functions

Cholesterol is transported in the bloodstream as particles called lipoproteins. While there are a few types of lipoproteins, the ones that are pertinent to take note of include:

Impact of High Blood Cholesterol Levels

High levels of cholesterol in the blood causes fatty deposits on the walls of blood vessels. As these fatty deposits accumulate overtime, they may eventually obstruct the flow of blood through the arteries. Insufficient blood supply and hence oxygen supply to the heart may result in a heart attack, while that to the brain may lead to a stroke.

In addition, research has found that elevated levels of LDL cholesterol causes inflammation and an increase in vasoconstriction activities triggered by certain hormones. This leads to blood vessels becoming narrower and stiffer. As a result, the heart has to pump harder to supply blood to other parts of the body, leading to high blood pressure.

How to Measure and Interpret Cholesterol Levels

As high blood cholesterol does not usually present with any symptoms, it is important to be screened so as to detect any abnormalities through either one of the following:

1.   Full lipid profile

A full lipid profile, also known as a lipid panel, is a comprehensive blood test that measures the amount of cholesterol and other fats in your blood. This test plays an important role in predicting one’s risk for heart disease and stroke by assessing various components, including:

2.   Finger prick test

Although not commonly done in Singapore, a finger prick blood test may be done to measure cholesterol levels. They offer a quick and convenient way to detect cholesterol levels. Similar to a full lipid profile, PreciS^TM-C Cholesterol Monitoring System also measures:

The level of LDL cholesterol is not directly obtained from the device. Instead, it is calculated from the values of total cholesterol, HDL cholesterol and triglyceride levels.

Recommended Cholesterol Levels

The Agency for Care Effectiveness (ACE) Clinical Guidance (ACG) recommends that the recommended cholesterol levels for each patient should be individualized. This is especially so as inter-individual variabilities play a significant role in the development and progress of hyperlipidemia. However, for a general guide on lipid levels, classification of lipid levels according to the MOH Clinical Practice Guidelines 2016 are as follows:

Measurement in mmol/L	Classification
Total Cholesterol
< 5.2	Desirable
5.2- 6.1	Borderline high
≥ 6.2	High
LDL Cholesterol
< 2.6	Optimal
2.6-3.3	Desirable
3.4- 4.0	Borderline high
4.1- 4.8	High
≥ 4.9	Very high
HDL Cholesterol
< 1.0	Low
1.0-1.5	Desirable
≥ 1.6	Optimal
Triglyceride
< 1.7	Optimal
1.7-2.2	Desirable
2.3- 4.4	High
≥ 4.5	Very high

Certain patients may require stricter LDL cholesterol targets for stroke and heart attack prevention especially if they have risk factors that predispose them to a secondary event. This includes patients with Atheroscleorotic Cardiovascular Disease (ASCVD) risk, including but not limited to a history of heart attack, unstable angina, ischemic stroke.

ACG recommends a LDL cholesterol target of <1.4mmol/L for patients with history of acute coronary syndrome (includes heart attack and unstable angina) and a target of <1.8mmol/L in other patients with ASCVD risk but lower targets may be considered based on clinical need and tolerability. For a comprehensive breakdown of the different targets, click here.

Frequency of cholesterol checks

Regular monitoring of your cholesterol levels, especially if you are on any cholesterol-lowering medication, is important for your healthcare provider to assess the efficacy of treatment as well as your risk of developing heart disease. This also helps your healthcare provider determine if there is any need to adjust your medications and care plan.

While it is important to note that recommended lipid levels and frequency of imonitoring may vary due to individual risk factors, MOH Singapore recommends the following general frequency for lipid level reviews:

Performance parameter	Recommended review frequency
All patients who are on stable lipid modifying drug therapy with LDL cholesterol target levels achieved.	Lipid measurement at least every 12 months
Patients who are not on lipid modifying drug therapy (with LDL cholesterol target levels achieved as stated above): (1) Very high risk and high risk (2) Intermediate risk and low risk	(1) Lipid measurement every 12 months (2) Lipid measurement every 3 years

Causes of High Cholesterol

Understanding the factors that may contribute to high cholesterol is paramount in its management. High cholesterol may be caused by several factors including:

1. Dietary factors

While many believe that dietary cholesterol from sources such as eggs, meat products and cheeses play a major role in affecting cholesterol levels, research suggests otherwise. In fact, Harvard researchers have found that the consumption of an egg a day is not associated with a higher risk of heart disease.

Meanwhile, the consumption of 2 main types of unhealthy fats, saturated and trans fats, cause your body to produce more LDL cholesterol. This contributes to elevated “bad” cholesterol levels in your blood and ultimately causes high cholesterol.

2. Lifestyle factors

Obesity tends to increase the levels of LDL cholesterol and lower the levels of HDL cholesterol. According to the Obesity Action Coalition, about 4.5kg of excess fat produces an additional 10mg of cholesterol daily.

While studies have shown that obesity increases the quantity of LDL cholesterol levels, a new study interestingly suggests that obesity also affects the quality of LDL cholesterol produced. Obesity-associated inflammation causes more of these cholesterol to adhere to the walls of the arteries, increasing the accumulation of fatty plaques and risk of heart diseases.

Physical inactivity and a sedentary lifestyle may increase the likelihood of developing high cholesterol. It was found that low physical activity since youth is associated with lower “good” HDL cholesterol. As HDL cholesterol helps to remove cholesterol from the blood circulation, low levels may subsequently increase risk of heart disease.

Other lifestyle factors such as excessive alcohol consumption and smoking also play a role in contributing to high cholesterol. Excessive alcohol consumption increases the level of total cholesterol while smoking is associated with increased accumulation of fatty deposits in the walls of the arteries. The latter may also reduce the levels of HDL cholesterol.

3. Other factors

There are also other contributing factors to high cholesterol. These include:

a. Age

While people of all ages can have high cholesterol, it is more common in people aged 40 and above.

b. Family history

Familial hypercholesterolaemia is an inherited condition where it is more challenging for the body to remove LDL cholesterol from the body, increasing the risk of heart attack and stroke even from an early age.

c. Underlying health conditions

Other health conditions may also increase one’s risk of developing high cholesterol. These include:

• Diabetes
• Kidney disease
• Polycystic ovary syndrome
• Thyroid problems
• Pregnancy

Stroke and Its Risk Factors

A stroke occurs when the blood supply to the brain is compromised. There are 2 main types of stroke:

1. Ischemic stroke

An ischemic stroke occurs when there is a blockage of blood flow in an artery within the brain. It may be due to a blood clot or the accumulation of fatty deposit and cholesterol in the artery.

2. Hemorrhagic stroke

A hemorrhagic stroke occurs when a blood vessel within the brain ruptures.This occurs when the pressure within the vessel builds up, eventually leading to its rupture.

When blood supply to the brain is compromised, the brain does not receive sufficient oxygen and brain cells may start to die within minutes. As the brain is responsible for many functional activities like moving, speaking, thinking and remembering, a stroke can be extremely debilitating and the importance of preventing its occurrence cannot be overstated.

To effectively prevent a stroke, it is crucial to be aware and address the risk factors that predisposes an individual to a stroke. These include but are not limited to:

• High blood pressure
• High cholesterol
• Diabetes
• Obesity
• Heart disease

Connecting Cholesterol to Stroke

High levels of LDL cholesterol is associated with an increased risk of stroke incidence. This happens when LDL cholesterol accumulates on the walls of arteries, forming fatty plaques and resulting in the narrowing of the arteries. This may then block blood perfusion to the brain, resulting in an ischemic stroke.

As a result, managing cholesterol levels with lifestyle changes and medication use play a crucial role in the prevention of stroke.

Lifestyle Changes to Reduce Cholesterol

Dietary Modifications

To reduce cholesterol in the blood, it is useful to consider diet modification including:

1. Decreasing consumption of foods high in saturated and trans fats such as 2. Incorporating foods high in soluble fiber and opting for healthier fats (monounsaturated and polyunsaturated fats) such as

Physical Activity and Weight Management

Research has shown that physical exercise is associated with higher levels of beneficial HDL cholesterol, lower levels of LDL cholesterol and has a positive impact on weight management.

It is recommended to have at least 30 minutes of exercise 5 times a week, or at least 20 minutes of vigorous aerobic activity 3 times a week. However, it is crucial to consult your healthcare professional before beginning on any new exercise regimens. Some exercises to consider adding to your daily routine may include:

1. Brisk walking
2. Riding a bike as a mode of transportation
3. Playing a favorite sport

Other Lifestyle Changes

As excessive consumption of alcohol may increase the level of total cholesterol, it is important to limit alcohol intake. A general guide would be to adhere to a maximum of 1 drink per day for women and 2 drinks per day for men. This not only helps in cholesterol management, but may also reduce your blood pressure and body weight.

For smokers, quitting smoking is highly beneficial as smoking harms your blood vessels and also reduces the levels of “good” HDL cholesterol in your blood. For more assistance on smoking cessation, click here.

Practice mindfulness activities such as yoga and meditation to relieve stress and improve mental well-being, consequently lowering your risk for heart disease.

Treatment Options for High Cholesterol

In the event where lifestyle changes are insufficient to manage cholesterol levels, it may be necessary to take medications to help lower your cholesterol levels.

Statins

The most common and extensively studied class of medication used to treat high cholesterol is statins. Statins work by inhibiting an enzyme that is involved in the production of cholesterol. At the same time, it helps to increase the removal of LDL from the blood. Depending on the doses and types of statins used, they can yield up to 60% reduction of LDL cholesterol levels. In addition, they may also reduce inflammation, thereby preventing heart attacks and strokes.

In Singapore, statins are Prescription-Only Medications. With a valid prescription from a doctor, you may order statins from Glovida-Rx conveniently. Examples of statins available at Glovida-Rx include:

A. Crestor (Rosuvastatin)

B. Lipitor (Atorvastatin)

C. Zocor (Simvastatin)

As with all medications, statins may also cause some side effects. Common side effects include:

• Mild muscle aches or weakness, or tiredness
• Stomach pain, constipation and diarrhea
• Headache, joint and back pain

It is also important to watch out for rare but serious side effects, including:

• Allergic reactions which presents as swollen face, lips, tongue and eyes, difficulty breathing and itchy rashes all over the body
• Muscle breakdown which presents as unexplained severe muscle pain, muscle weakness or cramps all over the body and dark brown urine
• Liver injury which presents as pale stools, dark brown urine, nausea and vomiting, loss of appetite and yellowing of the skin and eyes

As grapefruit juice may hinder the clearance of statins, avoid consuming grapefruit juice concomitantly with statins as it may increase the risk of side effects.

Other Lipid-Lowering Drugs

Besides statins, there are also other classes of medications available to help lower lipid levels. These medications are all Prescription-Only Medications and can only be obtained with a doctor’s valid prescription. Other lipid-lowering medications available at Glovida-Rx include:

A. Zetia (Ezetimibe)

Ezetimibe is usually added to statins for additional cholesterol control but sometimes also used alone in patients who cannot tolerate statins. It lowers LDL cholesterol by approximately 20% by reducing the intestinal absorption of cholesterol into the blood as well as decreasing the body’s production of cholesterol. Side effects of ezetimibe are similar to that of statins.

B. Lipanthyl Penta (Fenofibrate)

Fenofibrate may be used in high cholesterol as it works by increasing the activity of an enzyme that breaks down triglycerides, improving clearance of LDL cholesterol and it also has additional benefits of increasing HDL levels in the blood. Some side effects of fenofibrate include nausea, skin rashes, some inflammation of muscles and gallstones.

Newer Medications

Recent pharmacotherapy developments have introduced newer Prescription-Only Medications to lower cholesterol levels, offering additional options for individuals with high cholesterol. These medications include:

A. Leqvio (Inclisiran)

First approved for use in Singapore in 2021, Inclisiran is an injectable medication that works by decreasing the expression of an enzyme that causes an increase in LDL cholesterol. As such, LDL cholesterol levels decrease due to the reduction of this protein in liver cells.

Leqvio (Inclisiran) offers a convenient administration of 2 doses a year after the first 2 doses. Research has shown that patients who take inclisiran in addition to a maximally tolerated statin, reported a 50% reduction of LDL cholesterol.

B. Nexletol (Bempedoic Acid)

In 2020, the United States (US) Food and Drug Administration (FDA) approved Nexletol (bempedoic acid) for use in LDL cholesterol lowering. A novel LDL cholesterol-lowering medication, bempedoic acid significantly lowers the levels of LDL cholesterol in the blood when used together with a maximally tolerated statin.

It works by inhibiting an enzyme involved in cholesterol synthesis, consequently decreasing cholesterol synthesis in the liver and increasing the uptake and removal of LDL cholesterol in the blood.

Taking Control of Your Cholesterol Health with Glovida-Rx

Glovida-Rx offers a wide range of medications for high cholesterol. Our team of licensed pharmacists are equipped with the knowledge and expertise to provide valuable insights regarding therapeutic options available in Singapore. With emphasis on personalized care, our pharmacists are available for consultations via WhatsApp should you have any queries. At Glovida-Rx, Singapore’s premier online pharmacy, we value authenticity and affordability. Discover the comprehensive range of medications for cholesterol management here.

While general advice to better manage cholesterol levels are enclosed within this article, it is always beneficial to seek personalized advice from healthcare professionals to ensure appropriate and optimal treatment effectiveness. The management of high cholesterol to prevent stroke involves a proactive approach to incorporate lifestyle modifications and medication use. Embark on your journey to better health and stroke prevention with Glovida-Rx. Visit our website www.glovida-rx.com.sg for more information and contact our pharmacists at +65 8101 5555 today!

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