Management of the patient with a low HDL‐cholesterol

While there is epidemiologic evidence linking a low high‐density lipoprotein (HDL) cholesterol level with coronary disease events, and interventions that raise HDL while lowering low‐density lipoprotein (LDL) cholesterol levels have been shown to reduce subsequent coronary events, there are no studies showing benefit from raising HDL when a low HDL level is the sole lipid abnormality. HDL is thought to play a key role in reverse cholesterol transport, removing lipids from peripheral cells, but the precise role of HDL in cholesterol metabolism is not understood. The measurement of HDL levels has not been well standardized. Reliance on ratios relating HDL to LDL or to total cholesterol may be misleading in the management of patients. It has not been shown that measuring HDL subfractions or apolipoprotein levels is superior to measuring total HDL levels in predicting coronary risk. HDL levels may be raised by hygienic measures such as smoking cessation and exercise, but a considerable amount of exercise over a long period of time is required. Alcohol consumption and weight loss through dieting inconsistently raise HDL. Estrogen therapy raises and progestational agents lower HDL. Certain beta‐blocking drugs lower HDL levels. For the patient with an isolated low HDL level the hygienic measures may be advised, but drug therapy such as nicotinic acid or gemfibrozil should be prescribed only when low HDL is accompanied by elevated LDL levels that are unresponsive to diet and hygienic measures.