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CHOLESTEROL SERIES · ARTICLE 3 OF 12
The complications nobody wants to talk about
Heart attack, stroke and peripheral artery disease.
This is a difficult article. We put it third in the series on purpose. If you understand what high cholesterol does when you leave it alone, the rest of the series — the food, the walking, the medication — makes much more sense.
We are not writing this to frighten you. We are writing it because, in our experience, knowing the stakes is the single biggest motivator people have. The good news at the end of every section is the same: high cholesterol, treated, almost completely removes these risks. Untreated, the damage accumulates quietly for ten or twenty years and then arrives all at once.
What this article is and is not
This article describes what high cholesterol does over a long time when it is left untreated or treated badly. None of it is inevitable. None of it is automatic. The whole point of treating cholesterol — with food, with movement, with tablets — is to prevent every single thing in this article.
How cholesterol actually damages arteries
Picture your arteries as smooth, flexible pipes. The inside lining is one cell thick — a delicate layer called the endothelium. When too many LDL particles are circulating in the blood, some of them slip through this lining and get stuck in the artery wall. The body sends white blood cells to clean up the mess. The white blood cells get stuck too. What forms is a little inflamed bump inside the artery wall — a plaque.
Over years, the plaque grows. The artery becomes narrower; the wall becomes thicker and stiffer. Some plaques stay quiet for decades. Others crack open. When one cracks, the blood reacts as it would to any wound — it forms a clot. The clot blocks the artery completely. The tissue downstream — heart muscle, brain tissue, sometimes a leg — starts dying within minutes.
This process is called atherosclerosis. It is the single most common cause of death in South Africa, and the world. Almost every complication in this article is a different version of the same story — plaque, narrowing, rupture, clot, dead tissue downstream.
High cholesterol doesn’t cause heart attacks. The plaque it builds, slowly, over decades, causes heart attacks.
1. Heart attack
The arteries that feed the heart muscle itself are called the coronary arteries. They are small — about the width of a drinking straw — and they have a hard job, supplying a muscle that never rests. When cholesterol-driven plaque builds in a coronary artery and cracks, the resulting clot can stop blood flow to part of the heart muscle within seconds. That part of the muscle starts dying. This is a heart attack — medically called a myocardial infarction.
Heart attacks are the single biggest cause of premature death in South African adults. About 80% of them are driven by cholesterol-related coronary artery disease.
The warning signs
• A heavy, crushing pressure or squeezing in the centre of the chest, often spreading to the left arm, the jaw, the upper back, or sometimes the upper abdomen
• Shortness of breath, often disproportionate to the activity
• Cold sweat
• Nausea or vomiting
• A sense of doom — many survivors say they knew something was very wrong
Symptoms in women can be more subtle — extreme tiredness, jaw or back pain, indigestion-like discomfort — and often delay diagnosis.
If you suspect a heart attack
Stop what you are doing. Sit down. Chew (don’t swallow) one aspirin if there is one nearby and you are not allergic. Call 10177 for an ambulance. The first hour after symptoms start is when the most heart muscle can be saved.
Do not try to drive yourself to hospital. Do not wait it out to see if the symptoms pass. The earlier emergency treatment starts, the more of the heart can be saved.
What’s reversible
A heart attack treated within the first hour with clot-dissolving drugs (thrombolytics), an emergency stent (angioplasty), or surgery leaves much less damage than one treated late. Most South African public hospitals can give thrombolytics; major centres can do emergency stenting. Either way, time matters.
Heart muscle that has died doesn’t grow back. But further damage can almost always be prevented with statins, BP control, lifestyle change, and the right secondary-prevention medications.
2. Stroke
A stroke is what happens when blood stops reaching part of the brain. Without blood, brain cells start dying within minutes. The part of the body controlled by that area of brain stops working — speech, an arm, a leg, vision, balance.
High cholesterol drives the most common kind of stroke — the ischaemic stroke, where plaque in the neck arteries (carotids) or in the brain’s own arteries ruptures, forms a clot, and blocks the blood supply. About 80% of strokes in South Africa are this kind.
Spot a stroke — F.A.S.T.
Face — ask the person to smile. Does one side droop?
Arms — ask them to raise both arms. Does one drift down?
Speech — ask them to say a simple sentence. Is it slurred or strange?
Time — if any of these is wrong, call 10177 immediately. Every minute matters. The earlier treatment starts, the more of the brain can be saved.
What’s reversible
If treatment starts within the first 3 – 4 hours, much of the brain damage from an ischaemic stroke can be reversed with clot-dissolving drugs. Some larger centres can also do mechanical clot retrieval. Outside that window, recovery is slower and less complete. Six months of physiotherapy and speech therapy can do extraordinary things — but not everything.
The way to never need that recovery is to keep cholesterol under control in the years before any stroke happens. Lowering LDL by 1 mmol/L cuts stroke risk by about 15 – 20%; tighter control gives larger benefit.
3. Peripheral artery disease (PAD)
This is the cholesterol complication people talk about least, but it affects roughly 1 in 10 South Africans over 65. Plaque builds in the arteries that feed the legs. The leg muscles, starved of blood during exercise, start to ache.
The warning signs
• Calf or thigh pain on walking that goes away with rest — this is called intermittent claudication. A specific clue: the pain starts after a predictable distance (say, 100 metres), is reliably relieved by stopping, and returns again at the same distance next time.
• Cold, pale feet, especially on one side.
• Hair loss on the legs.
• Slow-healing sores on the feet or ankles, particularly in diabetics.
• Severe pain in the leg at rest, especially at night — a late and more dangerous sign.
What’s reversible
Early PAD responds well to walking (yes — even though it hurts, controlled exercise is the most effective non-surgical treatment), statins, and stopping smoking. Plaque doesn’t shrink dramatically, but blood flow improves through other smaller arteries. Severe PAD may need angioplasty or bypass surgery, and in the worst cases, amputation. People with diabetes are at much higher risk because nerve damage hides the early warning pain.
4. Carotid artery disease and aortic aneurysm
Two other places worth knowing about:
Carotid plaque
The carotid arteries in the neck supply blood to the brain. Plaque here can rupture and send small clots into the brain — causing a stroke or a “mini-stroke” (TIA — transient ischaemic attack). A TIA looks like a stroke but resolves within 24 hours. It is a critical warning sign. About 1 in 5 people who have a TIA will go on to have a full stroke within 3 months — most of those strokes are preventable if the TIA is taken seriously.
Aortic aneurysm
The aorta is the body’s largest artery, running from the heart down through the chest and abdomen. Years of cholesterol-driven damage can weaken its wall, causing it to balloon outward — an aneurysm. Most aneurysms have no symptoms until they rupture, which is usually fatal. Men over 65 who have smoked are at the highest risk and should ask for an abdominal ultrasound screen.
5. The kidneys, the eyes, and the brain (long-term)
Cholesterol contributes to damage in three more places, less dramatically but still importantly:
• Kidney disease. Plaque in the small kidney arteries reduces blood supply and accelerates the kidney damage caused by diabetes and high BP.
• Eye changes. Cholesterol plaques can lodge in the small arteries of the retina, sometimes visible as a “Hollenhorst plaque” at an eye exam. These are warning signs that bigger plaques exist in the carotids.
• Vascular dementia. The same small-vessel damage that drives vascular dementia in people with high BP is contributed to by high cholesterol. Long-term LDL control in middle age is one of the most reliable ways to protect the brain you’ll need at 75.
How much of this does treatment actually prevent?
The numbers below come from large international trials that have followed millions of people over decades. They describe the effect of bringing LDL down by 1 mmol/L through any combination of lifestyle and statin therapy.
Outcome Risk reduction per 1 mmol/L LDL drop Heart attack About 25% Ischaemic stroke About 15 – 20% Death from cardiovascular causes About 12% Need for stent or bypass surgery About 24% Peripheral artery disease progression About 20%
Many people need more than 1 mmol/L of reduction. Going from an LDL of 4.0 to 1.8 — typical for a high-risk patient starting a statin — is about 2.2 mmol/L of reduction, which roughly doubles every benefit in the table.
Every 1 mmol/L you bring your LDL down protects your heart, your brain, and your legs.
The bigger picture
Untreated high cholesterol is not a “maybe one day something might happen” condition. It is a slow, certain accumulation of damage. The damage is invisible for many years and then arrives all at once, in the form of a heart attack, a stroke, or sudden leg pain. By that point, much of the damage cannot be reversed.
The whole rest of this series — the food, the walking, the medication — is about preventing every single complication in this article. Most of them are preventable in most people, most of the time, if cholesterol is brought down and kept down. The treatment is cheap, accessible, and effective.
The next article in the series gets practical: how to read your lipid panel properly, what each number means for your personal risk, the newer markers some clinics now use (ApoB, Lp(a)), and how to talk to your nurse about your numbers.
Where to get more help
Heart and Stroke Foundation South Africa — heartfoundation.co.za · 021 422 1586.
In an emergency — 10177 for an ambulance, or get to your nearest hospital emergency department immediately.
Phila Today High Blood Pressure Series — Article 3 on BP complications covers much of the same damage from a different angle.
Phila Today Cholesterol Series — next: understanding your lipid panel — the four numbers and what they mean.
Phila Today · Article 3 of 12 in the Cholesterol Series