Just How Good is ‘Good’ Cholesterol?

By Jonathan Springston, Editor, Relias Media

The levels of low-density lipoprotein (LDL) and high-density lipoprotein (HDL) cholesterol, commonly known as “bad” and “good” cholesterol, respectively, often guide clinicians regarding cardiovascular disease (CVD) risk among their patients. But the authors of a recent investigation questioned how much importance physicians should place on HDL-C levels.

Researchers scrutinized data from the REasons for Geographic and Racial Differences in Stroke (REGARDS) study. In that study, there were 23,901 participants without coronary heart disease (CHD). These participants were similar in age; recorded similar cholesterol levels; and were living with relevant risk factors, such as high blood pressure or diabetes. Over a median 10 years of follow-up, CHD events occurred in 664 Black participants and in 951 white participants.

Those with higher LDL-C levels were at a higher risk for CVD; however, low levels of HDL-C were a predictor for CVD risk only among white participants, not Black participants.

“Our current understanding of how HDL-C contributes to CHD risk is primarily shaped by the Framingham heart study, where all cohorts (original, offspring, spouses) are 100% white American. Collective data from recent years suggest that we should develop a population-wide risk estimation algorithm that works in other races as well,” the authors wrote. “Our data suggest that the use of low HDL-C is informative in white adults but not in Black adults and the use of high HDL-C might not be helpful in either race. Although we need to gather further population-based evidence, our data support the notion that the value of high HDL-C in risk prediction algorithms should be demoted.”

It seems that to better understand heart health, clinicians should be using a wider lens. Indeed, the National Heart, Lung, and Blood Institute is considering a more comprehensive approach to measuring CVD and CHD risk, including updated models like the estimated atherosclerotic CVD (eASCVD) risk score.

In December 2019, the American Heart Association issued a scientific advisory in which the authors wrote “a recommendation that gives a specific dietary cholesterol target within the context of food-based advice is challenging for clinicians and consumers to implement; hence, guidance focused on dietary patterns is more likely to improve diet quality and to promote cardiovascular health.”

For more on this and related subjects, be sure to read the latest issues of Clinical Cardiology Alert.