Management of Low Levels of High-Density Lipoprotein-Cholesterol

A 61-year-old healthy man presents for a routine outpatient clinic visit. He was diagnosed with hypertension 6 years ago with blood pressure well controlled on amlodipine 5 mg daily. He is a lifelong nonsmoker and has no family history of premature coronary disease. He is employed as a business executive. Exercise is limited to 15 minutes of walking daily in transit to work. Diet includes frequent dining out with clients and occasional moderate alcohol consumption. Examination is notable for a blood pressure of 125/70 mm Hg and a body mass index of 32 kg/m2. A fasting lipid panel is notable for total cholesterol of 188 mg/dL, high-density lipoprotein-cholesterol (HDL-C) of 31 mg/dL, calculated low-density lipoprotein-cholesterol (LDL-C) of 125 mg/dL, and triglycerides of 160 mg/dL.A 58-year-old man with coronary artery disease presents for follow-up. When he was 50 years of age, chest discomfort led to diagnosis of a non–ST-segment elevation myocardial infarction. Cardiac catheterization revealed a 90% left anterior descending lesion, which was stented, and 40% left circumflex artery stenosis. A lipid profile was returned with total cholesterol of 180 mg/dL, LDL-C of 130 mg/dL, HDL-C of 28 mg/dL, and triglycerides of 150 mg/dL. In addition to other cardiovascular medications, the patient was treated with atorvastatin 80 mg. The follow-up LDL-C was 72 mg/dL, and HDL-C was 26 mg/dL; vital signs were well controlled. Four years ago, at 54 years of age, he re-presented with exertional chest discomfort. Stress testing led to repeat catheterization and stenting of a 90% left circumflex lesion and a 90% left anterior descending lesion distal to the previous intervention. Lipoprotein(a), checked because of a family history of premature coronary artery disease, was 110 mg/dL (upper limit of normal, 40 mg/dL). A trial of niacin was started, and titrated, which the patient tolerated. On 2 …