Clinical impact of direct HDLc and LDLc method bias in hypertriglyceridemia. A simulation study of the EAS-EFLM Collaborative Project Group

Atherosclerosis. 2014 Mar;233(1):83-90. doi: 10.1016/j.atherosclerosis.2013.12.016. Epub 2014 Jan 4.


Background: Despite international standardization programs for LDLc and HDLc measurements, results vary significantly with methods from different manufacturers. We aimed to simulate the impact of analytical error and hypertriglyceridemia on HDLc- and LDLc-based cardiovascular risk classification.

Methods: From the Dutch National EQA-2012 external quality assessment of 200 clinical laboratories, we examined data from normotriglyceridemic (∼ 1 mmol/l) and hypertriglyceridemic (∼ 7 mmol/l) serum pools with lipid target values assigned by the Lipid Reference Laboratory in Rotterdam. HDLc and LDLc were measured using direct methods of Abbott, Beckman, Siemens, Roche, Olympus, or Ortho Clinical Diagnostics. We simulated risk reclassification using HDL- and sex-specific SCORE multipliers considering two fictitious moderate-risk patients with initial SCORE 4% (man) and 3% (woman). Classification into high-risk treatment groups (LDLc >2.50 mmol/l) was compared between calculated LDLc and direct LDLc methods.

Results: Overall HDLc measurements in hypertriglyceridemic serum showed negative mean bias of -15%. HDL-multipliers falsely reclassified 70% of women and 43% of men to a high-risk (SCORE >5%) in hypertriglyceridemic serum (P < 0.0001 vs. normotriglyceridemic serum) with method-dependent risk reclassifications. Direct LDLc in hypertriglyceridemic serum showed positive mean bias with Abbott (+16%) and Beckman (+14%) and negative mean bias with Roche (-7%). In hypertriglyceridemic serum, 57% of direct LDLc measurements were above high-risk treatment goal (2.50 mmol/l) vs. 29% of direct LDLc (33% of calculated LDLc) in normotriglyceridemic sera.

Conclusion: LDLc and HDLc measurements are unreliable in severe hypertriglyceridemia, and should be applied with caution in SCORE risk classification and therapeutic strategies.

Keywords: HDL-cholesterol; Hypertriglyceridemia; LDL-cholesterol; Risk classification; SCORE; Treatment goals.

MeSH terms

  • Bias*
  • Cardiovascular Diseases / etiology
  • Cholesterol, HDL / blood*
  • Cholesterol, LDL / blood*
  • Diagnostic Errors / prevention & control
  • Female
  • Humans
  • Hypertriglyceridemia / diagnosis*
  • Male
  • Reproducibility of Results
  • Risk Factors


  • Cholesterol, HDL
  • Cholesterol, LDL