Arteriosclerosis, Thrombosis, and Vascular Biology. 1997;17:107-113
© 1997 American Heart Association, Inc.
Articles |
Isolated Low HDL Cholesterol As a Risk Factor for Coronary Heart Disease Mortality
A 21-Year Follow-up of 8000 Men
the Department of Epidemiology and Preventive Medicine and the Henry N. Neufeld Cardiac Research Center (U.G.), Sackler Medical Faculty, Tel Aviv University, Tel Hashomer, and the Computing Center (S.Y.), Bar-Ilan University, Ramat Gan, Israel, and the Department of Family Medicine (J.H.M.), Case Western Reserve University, Cleveland, Ohio.
Correspondence to U. Goldbourt, PhD, Neufeld Cardiac Research Institute, Sheba Medical Center, Tel Hashomer 52621, Israel. E-mail goldbu1@ccsg.tau.ac.il.
For the purpose of screening individuals at high risk for coronary heart disease (CHD), serum total cholesterol (TC) of 5.2 mmol/L has been set as a value dividing "desirable" from intermediate high or elevated levels, and HDL cholesterol (HDL-C) <0.9 mmol/L has been labeled as abnormally low, implying high CHD risk. It has been conjectured that low HDL-C poses no risk in the absence of elevated LDL cholesterol or TC. To assess the risk of CHD-free men with "isolated low HDL-C," ie, abnormally low HDL-C with desirable TC, we examined the CHD and all-cause mortality of some 8000 Israeli men aged 42 years and older during 1965 through 1986. Men with isolated low HDL-C represented one sixth of the cohort. CHD mortality among these men was 36% higher (age adjusted) than in counterparts with desirable TC, of which >0.9 mmol/L was contained in the high-density fraction. In men with TC>5.2 mmol/L, abnormally low HDL-C was associated with a virtually identical CHD mortality risk ratio, 38%. These findings persisted after adjustment for multiple CHD risk factors. The excess CHD risk associated with isolated low HDL-C appeared particularly increased in men with diabetes mellitus, whose death rate was 65% higher than in diabetics with HDL-C >0.9 mmol/L. A second subgroup result was consistent with equal CHD mortality risk among men in the "desirable" TC range, with or without low HDL-C, if systolic blood pressure was >160 mm Hg. These are post hoc findings, and hypotheses arising from these observations would require independent examination. Total mortality was not increased in men with isolated low HDL-C compared with men who had HDL-C <0.9 mmol/L and TC >5.2 mmol/L at baseline. These results indicate that an increased risk of CHD death is associated with abnormally low HDL-C for cholesterol ranges both below and above 5.2 mmol/L. For the individual, therefore, the risk is multiplied by the same amount regardless of TC. Quitting smoking, increasing physical activity, and decreasing body weight would all contribute to raise HDL-C in individuals of most or all age groups. When examined from a community perspective, the results are consistent with a relatively low population-attributable fraction among CHD-free men. This would tend to support the recommended practice of considering a TC level of 5.2 mmol/L (200 mg/dL) as a threshold for further evaluation in screened individuals without manifest CHD.
Key Words: HDL cholesterol • coronary heart disease • long-term mortality • preventive strategies
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