Risk determination of dyslipidemia in populations characterized by low levels of high-density lipoprotein cholesterol

Am Heart J. 2003 Dec;146(6):1052-9. doi: 10.1016/S0002-8703(03)00516-7.


Background: Current guidelines for managing dyslipidemia qualify patients for treatment based on low-density lipoprotein cholesterol (LDL-C) levels and other risk factors for coronary heart disease (CHD). However, when LDL-C is the sole lipid criterion for initiating therapy, patients with levels below the treatment initiation threshold who are at high risk because of low levels (<40 mg/dL) of high-density lipoprotein cholesterol (HDL-C) might not be identified. Twenty percent of male patients with CHD in the United States fall into this category. The total cholesterol/HDL-C (TC/HDL-C) ratio predicts CHD risk regardless of the absolute LDL-C and HDL-C.

Methods: We compared guidelines based on TC/HDL-C and LDL-C with those recommended by the National Cholesterol Education Program Adult Treatment Panel III (ATP III). Both sets of guidelines were applied to 9837 adults (>20 years of age) in the Turkish Heart Study, which has shown that 75% of men and 50% of women in Turkey have HDL-C <40 mg/dL.

Results: ATP III guidelines identified 14% of Turkish adults, 20 years or older, as candidates for lifestyle treatment only and an additional 18% for drug treatment. In conjunction with ATP III LDL-C thresholds, the TC/HDL-C ratio (>3.5, patients with CHD; > or =6.0, 2+ risk factors, > or =7.0, 0 to 1 risk factor) assigned lifestyle therapy alone to 18% and drug treatment to an additional 36%. Among primary prevention subjects at high risk because of age (men > or =45 years; women > or =55 years), both sets of guidelines prescribed lifestyle therapy for only 5%; however, drug treatment was recommended for an additional 13% by ATP III guidelines and an additional 18% by TC/HDL-C and LDL-C.

Conclusions: In populations at risk for CHD caused by low HDL-C, qualification of subjects for treatment based on either the TC/HDL-C ratio or LDL-C thresholds identifies more high-risk subjects for treatment than LDL-C threshold values alone, and use of the ratio, instead of risk tables, simplifies the approach for physicians.

MeSH terms

  • Adult
  • Age Factors
  • Body Mass Index
  • Cholesterol, HDL / blood*
  • Cholesterol, LDL / blood*
  • Cohort Studies
  • Coronary Disease / blood*
  • Female
  • Humans
  • Hyperlipidemias / blood*
  • Hyperlipidemias / diagnosis
  • Hyperlipidemias / drug therapy
  • Male
  • Practice Guidelines as Topic
  • Risk Factors
  • Sex Factors
  • Triglycerides / blood*
  • Turkey


  • Cholesterol, HDL
  • Cholesterol, LDL
  • Triglycerides