The epidemiology of low levels of high-density lipoprotein cholesterol in patients with and without coronary artery disease

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Abstract

Low levels of high-density lipoprotein cholesterol (HDL-C), and elevated total cholesterol-to-HDL-C ratios are independently associated with increased risk of coronary artery disease. In observational studies, every 1-mg/dL increment in HDL-C is associated with a 2% decreased risk of coronary artery disease in men and 3% decreased risk in women. On average, HDL-C levels are lower in men than in women, and are lower in whites than in blacks. Low HDL-C has also been found to be linked to higher risk of ischemic stroke, degree of carotid atherosclerosis, increased atherosclerotic progression as measured by coronary arteriography, higher coronary mortality among people with cardiovascular disease, and the development of coronary artery disease among patients with diabetes mellitus.

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Evidence from large prospective studies

Gordon et al3 analyzed the relation between HDL-C and incidence of coronary artery disease in the Framingham Heart Study, Lipid Research Clinics Prevalence Mortality Follow-up Study, Coronary Primary Prevention Trial control group, and the Multiple Risk Factor Intervention Trial control group. The analysis was confined to white men and women 30–69 years of age who were free of clinical symptoms of coronary artery disease. Results from these 4 prospective observational studies showed that for

Prevalence of low HDL-C in populations with and without coronary artery disease

In the United States, women ≥20 years of age have a higher mean HDL-C than men (56 mg/dL vs 47 mg/dL).10 Mean HDL-C levels are relatively constant across age groups for both women and men. Non-Hispanic black men and women have higher mean HDL-C levels than Mexican-American and non-Hispanic white men and women (Table 1). 10 In the general adult population in the United States, approximately 15% of men and 5% of women have HDL-C <35 mg/dL.

Fasting lipid panels were measured in >8,500 free-living

Cerebrovascular disease, carotid disease, and angiographically documented coronary artery disease

Data from the 21-year follow-up of the Israeli Ischemic Heart Disease Study were analyzed to look for associations between lipoprotein levels and stroke.13 An independent negative association between HDL-C and ischemic stroke mortality was found through multivariate analysis. Men in the lowest HDL-C tertile had a 1.32-fold increase in risk of dying from stroke than did those in the highest tertile for HDL-C (95% CI, 0.95 to 1.83).

The Kuopio Ischemic Heart Disease Study was a cross-sectional

Diabetes mellitus and HDL-C

Patients with diabetes, impaired glucose tolerance, or insulin resistance are particularly at risk for coronary artery disease. Men and women with and without type 2 diabetes in the Framingham Heart Study were analyzed to look for associations between presence of diabetes and serum lipids and lipoproteins.18 Type 2 diabetes was significantly associated with higher triglycerides and lower HDL-C. Diabetes was also associated significantly with higher concentrations of very low-density lipoprotein

Conclusion

Several prospective epidemiologic studies have found that serum HDL-C concentrations are an independent risk factor for coronary artery disease. Women have higher HDL-C levels than men, and non-Hispanic black men and women have higher mean HDL-C levels than their Mexican-American and non-Hispanic white counterparts. The prevalence of low HDL-C (<35 mg/dL) in the United States is approximately 15% among the general adult male population and approximately 5% among the general adult female

Points of concurrence

  • Observational studies have shown that low HDL-C is an independent risk factor for coronary artery disease events in patients with and without baseline cardiovascular disease.

  • Low HDL-C is associated with an increased incidence of carotid disease and ischemic stroke.

  • Low HDL-C is strongly inversely associated with type 2 diabetes and markedly increases the coronary artery disease risk in diabetic patients.

References (19)

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