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Don't count out HDL: although studies find no protective benefit of raising HDL, this 'good' cholesterol remains a key indicator of your cardiovascular health.

Higher levels of high-density lipoprotein (HDL) cholesterol are considered protective against cardiovascular disease. Whereas low-density lipoprotein (LDL) transports cholesterol into the artery wall, HDL carries cholesterol away from your arteries and back to the liver, where it's removed from the body. That's why HDL is considered "good" cholesterol, while LDL is labeled as "bad."

Unfortunately, the "good" cholesterol has gotten a bad rap from several recent studies, which cast doubt on the benefits of raising HDL levels to prevent cardiovascular events in people at high risk. Trouble is, other characteristics of HDL besides the total amount may correlate with heart attack and stroke risk, and simply increasing HDL cholesterol may not be the key to cardiac protection, a Cleveland Clinic expert says.

Despite the study findings, a low HDL level remains a red flag for greater cardiac risk, and it should prompt more aggressive efforts to improve your overall cardiovascular risk profile. "It's not time to ignore HDL, because there's so much data that argues that HDL is linked to cardiovascular disease," says Stanley Hazen, MD, PhD, Head of Preventive Cardiology & Cardiac Rehabilitation at Cleveland Clinic. "HDL cholesterol is a strong predictor of cardiac risk, but that does not mean raising HDL cholesterol will definitely lower cardiac events."


                          Low risk        Average         High risk

HDL "good"        [greater than or    50-59 mg/dL   <40 mg/dL (men)
cholesterol     equal to] 60 mg/dL         (good)         <50 mg/dL
                      (protective)                          (women)

LDL "bad"               <100 mg/dL  130-159 mg/dL  [greater than or
cholesterol *            (optimal)                    equal to] 160

               100-129 mg/dL (near                 [greater than or
                          optimal)                    equal to] 190
                                                        mg/dL (very

                       < 100 mg/dL                    200-499 mg/dL
                         (optimal)                           (high)

Triglycerides        100-149 mg/dL  150-199 mg/dL  [greater than or
                          (normal)                    equal to] 500
                                                        mg/dL (very

* Cleveland Clinic experts recommend an LDL goal of <70 mg/dL.
for patients at high and very high cardiac risk, <100 mg/dL
for those at intermediate risk, and <130 mg/dL for those at
low risk.


Despite achieving treatment goals with LDL-lowering statin drugs, many patients remain at risk of heart attack and stroke. Seeking ways to trim this residual risk, researchers have studied niacin and other drugs that raise HDL levels.

The results have been disappointing. In the AIM-HIGH trial, published in 2011, niacin improved HDL and triglyceride levels but provided no additional benefit among statin patients with established cardiovascular disease and LDL levels below 70 mg/dL.

Likewise, a study presented in March at the American College of Cardiology's 2013 annual meeting found that a combination of niacin and the anti-flushing drug laropiprant did not significantly reduce the risk of cardiovascular events compared with statin therapy among high-risk patients. Ask your physician if you should take niacin.

The disappointing results don't stop at niacin. A new drug, dalcetrapib, increased HDL cholesterol levels by about 30 percent among nearly 16,000 patients, but that HDL boost did not translate into lower cardiac risk, according to findings published Nov. 29, 2012, in the New England Journal of Medicine.

HDL not only is responsible for cholesterol transport, but it also has many other biologic roles and properties. So experts theorize that the functional quality of HDL, rather than the quantity, may be responsible for its cardioprotective abilities. "We focus on the cholesterol in the HDL particle, but the HDL particle has so many different functions," Dr. Hazen adds. "It could be that not raising HDL cholesterol but rather raising alternative HDL function may be what truly needs to be the goal for treating heart disease."


An HDL cholesterol level of 60 milligrams per deciliter (mg/dL) is considered protective against heart disease, while a level below 40 mg/dL for men (50 mg/dL for women) suggests increased cardiovascular risk. Increasing your HDL cholesterol significantly is very challenging. However, you can help maintain a healthy HDL level with sustained lifestyle efforts, including eating a low-fat, low-calorie diet, maintaining an optimal weight, and, especially, regular exercise.

HDL cholesterol remains an important marker of cardiovascular risk, but the recent study findings only re-emphasize the fact that high HDL cholesterol levels don't offset the risks posed by abnormal LDL cholesterol levels, Dr. Hazen says. If your HDL cholesterol is low, you need to be even more diligent in managing your LDL cholesterol and other cardiovascular risk factors.

"What has to remain important is that these recent studies do not undermine the importance of the HDL particle in cardiovascular disease," Dr. Hazen says. "If you have a low HDL cholesterol, you have all the more reason to focus on getting your LDL cholesterol down, as well as controlling your blood pressure and diabetes, following an exercise program, eating right, and doing all the other healthy things. What the low HDL cholesterol is telling us is that if you have risk, you can't ignore it, but we don't chase after raising the low HDL cholesterol at the current time."


If you can check off all the items on this list, you're helping your heart:

* HDL ("good") cholesterol >40 mg/dL

* LDL ("bad") cholesterol <100 mg/dL (<70 mg/dL if you have heart disease

* Triglycerides <150 mg/dL

* Blood pressure <140/90 mmHg

* Hemoglobin A1c <7 percent

* Cholesterol, blood pressure, and diabetes medications (as prescribed)

* Saturated fat and trans fat consumption <7 percent of daily calories

* Carbohydrate intake limited to 45-50 percent of daily calories

* Minimal sugar consumption.

* No smoking/smoking cessation

* At least 45 minutes of aerobic exercise (e.g. brisk walking, biking, or swimming) five days a week

* Normal weight: waist circumference <40 inches; body mass index 18.5-24.9 (calculate by dividing your weight in pounds by your height in inches squared and multiplying by 703)
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Publication:Men's Health Advisor
Date:Jun 1, 2013
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