High HDL-C Plus High LDL-C: To Treat or Not to Treat?

December 31, 2006

A number of my patients have very high high-density lipoprotein cholesterol (HDL-C)levels as well as elevated total cholesterol and low-density lipoprotein cholesterol(LDL-C) levels. One such patient is a nonsmoking middle-aged woman whose weightand blood pressure are normal.

A number of my patients have very high high-density lipoprotein cholesterol (HDL-C)levels as well as elevated total cholesterol and low-density lipoprotein cholesterol(LDL-C) levels. One such patient is a nonsmoking middle-aged woman whose weightand blood pressure are normal. Her total cholesterol level is 306 mg/dL; HDL-C,108 mg/dL; LDL-C, 185 mg/dL; and triglycerides, 66 mg/dL. Her father had amyocardial infarction at age 72. What treatment, if any, do you recommend for thispatient?---- Robert L. D'Agostino, MD
Canton, Mass
According to the third report of the National Cholesterol EducationProgram (ATP III), a high HDL-C level (ie, above 60 mg/dL) reducesthe tally of risk factors by one.1 Moreover, high HDL-C makesit unlikely that the metabolic syndrome is present; low HDL-C isoften associated with this syndrome. Thus, it is not surprising that inthe Framingham Study, high HDL-C was associated with a reduced risk of coronaryheart disease (CHD).2 If, for example, your patient is 60 years old and hersystolic blood pressure is 130 mm Hg, her risk of CHD is about 2%, accordingto the Framingham risk calculator.1Because the patient has 0 to 1 risk factors, the ATP III guidelines recommendthat LDL-C be lowered to below 160 mg/dL, with an emphasis on lifestylechange. There are no clinical data to support statin therapy in this low-risk patient.Nonetheless, some clinicians may consider statin therapy if additional riskfactor assessment indicates that the patient is at higher risk than initially believed.For example, a striking family history of premature CHD in a first-degreerelative or the presence of an emerging risk factor, such as a high C-reactive proteinlevel or a high coronary calcium score, might influence some clinicians totreat to a lower LDL-C goal (ie, less than 130 mg/dL). Clinical trials that are nowexamining the role of markers such as high-sensitivity C-reactive protein mayprovide evidence as to whether such an approach would be useful. If the patienthad evidence of CHD or had a much higher risk factor profile, treatment ofLDL-C to the appropriate lower ATP III goals would be indicated, in spite of herhigh HDL-C.---- Neil J. Stone, MD
Professor of Internal Medicine
Northwestern University
Chicago

References:

REFERENCES:
1.

Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executivesummary of the Third Report of the National Cholesterol Educational Program (NCEP) Expert Panel onDetection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III).

JAMA.

2001;285:2486-2497.

2.

Gordon T, Castelli WP, Hjortland MC, et al. High density lipoprotein as a protective factor against coronaryheart disease. The Framingham Study.

Am J Med.

1977;62:707-714.