The place of HDL in cholesterol management. A perspective from the National Cholesterol Education Program

The guidelines developed by the Adult Treatment Panel of the National Cholesterol Education Program identified low density lipoprotein (LDL) as the major atherogenic lipoprotein, and high levels of LDL-cholesterol as the primary target for cholesterol-lowering therapy. Low levels of high density lipoprotein (HDL)-cholesterol were recognized as a major risk factor for coronary heart disease. This report reexamines in depth the recommendations for Adult Treatment Panel on HDL-cholesterol. Two major questions are discussed: (1) Should HDL-cholesterol levels be measured in all adults, as recommended for total cholesterol? (2) Should patients found to have a low serum LDL-cholesterol level (<35 mg/dL [<0.91 mmol/L]) enter medical therapy to raise the level? The guidelines of the Adult Treatment Panel are reaffirmed as appropriate from the current perspective. These guidelines recommend that HDL-cholesterol levels be determined in patients deemed to be at high risk for coronary heart disease and suggest that HDL measurement is optional for individuals with borderline-high total levels. The guidelines of the Adult Treatment Panel recommend that low HDL-cholesterol levels be raised mainly by hygienic means (ie, smoking cessation, weight loss, aerobic exercise). When drug therapy is required for high LDL-cholesterol levels in the presence of low HDL levels, cholesterol-lowering drugs that concomitantly raise HDL should be given first priority.