"Cholesterol is a lifelong, cumulative risk. In many cases, starting management after your 40s is already too late."
Kausik Ray, a cardiology professor at Imperial College London in the United Kingdom, met with ChosunBiz on the 11th and warned, "Cholesterol that accumulates in the blood vessels exponentially increases risk with age."
Professor Ray visited Korea to deliver a keynote lecture at the Korean Society of Lipid and Atherosclerosis (ICoLA 2025), held at Conrad Seoul Hotel from the 11th to the 13th. Ray, a world authority in preventive cardiology who has published more than 400 research papers with over 180,000 citations, served as president of the European Atherosclerosis Society (EAS).
If "dyslipidemia (hyperlipidemia)," in which blood cholesterol and triglyceride levels are abnormal, is left untreated, it progresses to "atherosclerosis" in which blood vessels narrow or become blocked, leading to impaired blood flow. This is a major cause of cardiocerebrovascular diseases such as myocardial infarction and stroke. Cholesterol that builds up on the vessel wall gradually grows and, as immune and inflammatory cells are recruited, develops into plaque that accumulates inside the vessel wall, creating inflammation and scar tissue; as a result, clots form and block or rupture the vessel.
Ray said, "If the coronary artery is blocked by plaque, it leads to myocardial infarction; if a cerebral vessel is blocked, to stroke; and if a leg vessel is blocked, to peripheral artery disease," adding, "But many patients only learn they had plaque in their vessels after collapsing from a myocardial infarction or stroke."
Even healthy people in their 30s should not be complacent. Ray said, "Many adults in their 30s to 50s who look healthy on the outside already have plaque buildup," adding, "Global studies show that plaque is found in about one in six adults in their 20s, and half of them already had early-stage plaque."
This means plaque formation begins at a fairly young age. Treatment paradigms are changing accordingly. Ray said, "We need to move away from strategies that targeted only high-risk patients and adopt a 'lifetime risk' approach that manages even somewhat low blood cholesterol from a young age."
He said, "Set different LDL cholesterol targets based on risk level, and for high-risk groups, it is necessary to start intensive pharmacotherapy early."
Coronary artery calcium scoring, computed tomography (CT), and angiography are used to diagnose atherosclerosis. Medication is not determined by plaque burden alone; instead, treatment strategy is planned by calculating 5-, 10-, and 20-year risk based on a comprehensive assessment of age, sex, smoking status, cholesterol levels, blood pressure, and more.
The prevalence of dyslipidemia is rising across Northeast Asia, including Korea. Westernized diets, obesity, and diabetes are cited as the main causes. Family history also plays a role. When there is a family history, cholesterol is high from birth and long-term management is required.
Medication is the core of treatment. Ray said, "For patients at high cardiovascular risk, the first-line drugs are statins," adding, "In addition to statins like rosuvastatin, there are ezetimibe, which blocks cholesterol absorption in the gut; PCSK9 inhibitors, a liver-produced protein–targeting therapy; and small interfering RNA (siRNA) drugs given twice a year."
Ray said, "With more drug options, personalized treatment has become possible," adding, "The earlier treatment starts, the greater the health benefits, so the return on investment (ROI) of early therapy is very high." He explained, "For every 38 mg per deciliter (dL) reduction in low-density lipoprotein cholesterol (LDL-C), cardiovascular risk falls by about 22 percent," noting that "clinical results have even reported reversal of atherosclerosis progression with high-dose rosuvastatin."
Ray pointed out that intermittent fasting, the ketogenic diet, which reduces carbohydrate intake and increases fat intake, and the use of health supplements have limited scientific evidence.
He warned, "Intermittent fasting helps with weight loss, but the evidence that it directly improves vascular health is insufficient," adding, "In particular, the ketogenic diet may raise cholesterol levels and promote plaque formation due to increased saturated fat intake."
Regarding health supplements containing red yeast rice (hongkuk), known to be effective for cardiovascular disease, he said, "Monacolin K, a natural compound in red yeast rice, may have some cholesterol-lowering effect, but because its safety is not verified like a pharmaceutical, the risk of side effects is high." He added, "In fact, Japan has reported cases of acute kidney injury after taking related supplements," urging caution.
Ray advised, "Monacolin K inhibits cholesterol synthesis in the same way as statins, but in the long run, drug therapy with established safety and evidence is more reasonable than supplements."
☞Dyslipidemia
This refers to cases in which total cholesterol in the blood or low-density lipoprotein (LDL) cholesterol, the so-called bad cholesterol, is high; triglycerides are high; or high-density lipoprotein (HDL) cholesterol, known as good cholesterol, is low. The general thresholds are: △ total cholesterol 240 mg/dL or higher, △ LDL cholesterol 160 mg/dL or higher, △ HDL cholesterol less than 40 mg/dL, △ triglycerides 200 mg/dL or higher. If even one of the four criteria is abnormal, it can be called dyslipidemia. Diagnosis is usually made by measuring total cholesterol, triglycerides, HDL cholesterol, and LDL cholesterol in fasting blood.