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Goals for Cholesterol
Q. I am 57 years old, and as far as I know, my health is excellent. At my last check-up, my doctor said that I was in perfect health except that my cholesterol was too high. Please tell me what you think of these results: cholesterol 243, LDL cholesterol 162, HDL cholesterol 68, and triglycerides 86. Everything else was "normal."
A. Congratulations on being healthy — and on getting regular check-ups. Congratulations, too, on being a thoughtful patient who takes an interest in the fine print of your results.
Our goals for cholesterol have changed considerably over the years, and they are sure to evolve further as we learn more about the interplay between blood cholesterol levels and other cardiovascular risk factors. Since you are healthy, let's start by considering the guidelines that apply to you. Table 1 lists the standards established by the authoritative National Cholesterol Education Program Adult Treatment Panel III.
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Table 1: Cholesterol goals for healthy adults
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Total cholesterol
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Below 200 mg/dL
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Desirable
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200–239 mg/dL
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Borderline high
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240 mg/dL or above
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High
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LDL ("bad") cholesterol
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Below 100 mg/dL
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Optimal
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100–129 mg/dL
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Near or above optimal
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130–159 mg/dL
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Borderline high
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160–189 mg/dL
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High
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190 mg/dL or above
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Very high
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HDL ("good") cholesterol
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Below 40 mg/dL
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Low
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40–59 mg/dL
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Desirable
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60 mg/dL or above
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Optimal
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According to these guidelines, your total cholesterol and LDL are indeed high. But although your doctor is right, that doesn't mean you are at an increased risk of heart disease. Your HDL cholesterol is also high, and since HDL is the "good" cholesterol, that's reassuring.
Which counts more, your undesirable LDL or your excellent HDL? Most medical studies concentrate on the LDL, perhaps because doctors have drugs that are excellent at lowering the LDL but not so good at boosting the HDL. But a 2006 report from the Framingham Heart Study reminds us that HDL is very important in its own right.
The subjects were 5,251 men and women between the ages of 30 and 74 when the study began in 1971. Each volunteer had a detailed medical evaluation, including cholesterol testing, when they enrolled in the study. All were free of heart disease initially, but over the next 20 years, 566 men and 327 women were diagnosed with coronary artery disease. In both men and women, the LDL cholesterol level predicted risk, but in men the effect was surprisingly modest; men with the very highest LDL levels were only 1.85 times more likely to develop heart disease than those with the very lowest levels. The HDL cholesterol was a more powerful predictor, especially in men — but in this case, men with the highest HDL had the lowest risk.
How should you interpret one good number and one bad number? One approach would be to use a high-sensitivity C-reactive protein (CRP) level as a tie-breaker. CRP is an independent predictor of risk, so a high result might give you cause for worry while a low result would be reassuring. But that would require an additional blood test. The Framingham Heart Study has another idea. If you simply divide the total cholesterol by the HDL cholesterol, you derive a single risk ratio. The lower the ratio, the lower the risk.
According to the 2006 report, men with total- cholesterol-to-HDL results below 4.2 had low risk, even if their LDL numbers were very high. Conversely, a high ratio nearly tripled the likelihood that a man would develop heart disease. In this study, risk began to rise to significant levels in men with ratios above 5.5.
Your ratio is just 3.6, so you have no cause for concern. Don't rest on your laurels, though, since your numbers can never be too good; keep up your good work with a healthy lifestyle.
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Table 2: Goals for LDL cholesterol
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Risk category
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LDL goal
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Optional LDL goal
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Very high risk
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Acute coronary artery syndromes
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Below 70 mg/dL
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—
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High risk
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Stable coronary artery disease
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Below 100 mg/dL
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Below 70 mg/dL
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Atherosclerosis
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Diabetes
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Hypertension
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Multiple cardiac risk factors*
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Moderate risk
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Two or more cardiac risk factors*
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Below 130 mg/dL
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Below 100 mg/dL
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Low risk
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0–1 cardiac risk factor*
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Below 160 mg/dL
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Below 130 mg/dL
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*Risk factors include cigarette smoking; high blood pressure (over 140/90 mm Hg or on treatment); low HDL cholesterol (under 40 mg/dL); a family history of premature coronary artery disease in a parent or sibling (below age 55 in a male, 65 in a female); and age (over 45 in men, 65 in women).
All individuals who are above their goals should follow a therapeutic lifestyle that includes diet, exercise, weight control, and tobacco avoidance. Drug therapy may be needed to achieve these goals; medication is usually needed to reduce LDL cholesterol to 100 mg/dL and is almost always needed to reduce it to 70 mg/dL. Most patients will benefit from a statin drug, with additional drugs if necessary; a fibrate or nicotinic acid may be used to raise HDL cholesterol or lower triglyceride levels.
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Developed from updated recommendations of the National Cholesterol Education Program, Circulation 2004; 110:227–39.
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Although you shouldn't fret about your LDL of 162, many of your fellow readers have medical problems or risk factors that call for drastically lower LDLs. To save them the trouble of sending in their question, Table 2 summarizes the goals for people less fortunate than you.
— Harvey B. Simon, M.D. Editor, Harvard Men's Health Watch