QUESTION

When I got my most recent blood work, my HDL level was 89, which I thought was pretty good for a 57-year-old woman. However, that number was quite a bit higher than the range listed on the lab report. Is it possible to have too much of this “good” cholesterol?

ANSWER

Yes, it is possible. In fact, the thinking on high-density lipoprotein (HDL) cholesterol has recently undergone a dramatic shift. As you mentioned, HDL has traditionally been known as the “good” cholesterol. That’s because it generally carries harmful fats in the artery wall to the liver for processing. Women have been told to aim for an HDL level of at least 50 mg/dL because lower levels are linked to a higher risk for cardiovascular disease (CVD). In men, a level of 40 mg/dL or below is associated with increased odds of developing CVD. Once a patient has met the minimum threshold for HDL, doctors have long-assumed that the higher the level of this cholesterol, the better. However, scientists have now learned that the function of HDL is more important than the level of HDL. In fact, high HDL levels may not always help protect against CVD. Here’s why: As more has been discovered about the structure and function of HDL, it’s become clear that HDL can be either helpful by playing an anti-inflammatory/antioxidant role…or harmful by possibly promoting inflammation and oxidation. In addition, the ability of HDL to remove cholesterol from the artery wall can be variable. Research conducted by scientists at the University of Copenhagen, published in the European Heart Journal, shows this dichotomy. In the study, which analyzed health records for 116,000 adults, the researchers found that women with extremely high levels of HDL had a 68% higher risk of dying during the six-year study period than those with normal levels…for men, extremely high HDL was linked to a 106% higher risk for death. Also, while epidemiology research confirmed the well-established risk for extremely low levels of HDL, the risk or benefit of HDL is dependent on HDL function rather than absolute levels. So how can you tell what your HDL level means? When looking at one’s risk for CVD, the key is to remember that your HDL level is only one way that doctors assess this. More important are your levels of low-density lipoprotein (LDL) cholesterol, the so-called the “bad” cholesterol, and blood fats known as triglycerides—both of which must also be factored into your CVD risk profile. While most guidelines recommend an LDL level of less than 100 mg/dL, clinical studies show that optimal levels are below 70 mg/dL. The optimal level for triglycerides is less than 100 mg/dL. Your level of the inflammation marker C-reactive protein (CRP) is also helpful is assessing your risk for CVD—2 mg/L or above is associated with increased odds of having a heart attack or stroke. What I also recommend: A test for a key protein known as apolipoprotein-B (Apo-B). It appears on the surface of all cholesterol particles that can enter the artery walls and potentially lead to dangerous plaque buildup. Patients should aim for an optimal level of less than 60 mg/dL. A high apoB level more accurately predicts CVD risk than elevated LDL levels. You can ask for this test along with your standard lipid panel. Some health insurers will cover the cost. Bottom line: Especially if you have risk factors for CVD, such as high blood pressure, diabetes and/or a family history of early heart disease, talk to your doctor about the best tests to monitor your levels of cholesterol and other lipid levels. It’s wise for everyone to follow well-established heart-healthy habits to keep CVD risk in check. Eat a healthful diet, such as a Mediterranean-style plan with lots of fruits, vegetables, fatty fish and whole grains…exercise for at least 30 minutes on most days…maintain normal body weight…avoid smoking…manage stress…and get good-quality sleep. Depending on your overall risk for CVD, you may also require medication, including a statin and/or newer types of lipid-lowering drugs such as cholesterol absorption inhibitors—for example, ezetimibe (Zetia)—and PCSK9 inhibitors, such as alirocumab (Praluent) or evolocumab (Repatha). For additional heart-healthy secrets—including a simple practice to do first thing every morning—read here.