So What's the New Deal with HDL Cholesterol?
For decades, doctors have been telling patients the same reassuring message: "Your good cholesterol is protecting you from your bad cholesterol." High HDL was the gold star on lab results, the number that could supposedly offset a less-than-perfect LDL. But here's the thing, that whole story just got rewritten, and it changed how we talk to patients about cholesterol.
The Old Story We All Believed
I remember when HDL cholesterol was our go-to cardiovascular superhero story. We'd call it "good cholesterol" and explain it like this: HDL particles act like tiny garbage trucks, cruising through your bloodstream and picking up excess cholesterol from your artery walls, then hauling it back to your liver for disposal. Higher HDL meant more garbage trucks working overtime to keep your arteries clean.
This made perfect sense to both doctors and patients. If LDL was the villain dumping cholesterol into arteries, then HDL was the hero cleaning it up.We’d literally tell patients, "Don't worry too much about that slightly elevated LDL: your HDL is high enough to balance it out." We had treatment goals for HDL, just like we did for LDL. Some doctors even prescribed medications specifically to boost HDL levels.
The math seemed simple. Bad cholesterol minus good cholesterol equals your real risk.
When the Science Stopped Adding Up
But then something uncomfortable happened. data didn't match our beautiful theory.
Multiple large studies tried to prove that raising HDL would prevent heart attacks and strokes. Researchers gave people niacin, fibrates, and other drugs that successfully boosted HDL levels. The HDL numbers went up exactly as planned. Yet patients didn't have fewer heart attacks. Some studies showed slight increases in cardiovascular events.
The most damning evidence came from genetic studies that completely blindsided the medical community. Researchers found people born with naturally high HDL levels: genetic lottery winners with HDL over 100 mg/dL. If our theory was correct, these people should have been nearly immune to heart disease. They weren't. Their cardiovascular risk was about the same as everyone else.
Medicine had to admit it was wrong.
The Plot Twist Nobody Saw Coming
Recent research revealed something that completely flipped our understanding. It turns out the relationship between HDL and heart disease risk isn't a straight line: it's U-shaped. Yes, people with very low HDL (under 40 mg/dL for men, under 50 mg/dL for women) do have higher cardiovascular risk. But people with extremely high HDL (over 80-90 mg/dL) also showed increased risk of adverse outcomes.
Scientists discovered that not all HDL particles work the same way. Some HDL particles are great at that garbage truck function we used to describe, while others just cruise around not doing much of anything. The total HDL number on lab reports doesn't tell us which type a patient has.
I now explain it like this: measuring total HDL is like counting all the trucks in a city without knowing which ones are actually picking up garbage and which ones are just driving around empty.
How We Practice Now
Here's how medical practice has changed: major medical organizations, including the American College of Cardiology and American Heart Association, no longer recommend targeting specific HDL levels or using medications to raise HDL for heart disease prevention.
I don't prescribe niacin to boost HDL anymore. When I see slightly low HDL on lab results, I don't panic or aggressively treat it with drugs. And that old reassurance we used to give about high HDL canceling out moderately elevated LDL? That's completely off the table.
We still consider low HDL a risk marker: it tells us something about a patient's overall cardiovascular risk. But it's not a treatment target anymore.
The New Focus: Keep It Simple
After all the sophisticated research, advanced particle testing, and complex theories about different types of cholesterol, we've learned the answer is refreshingly straightforward: get LDL as low as safely possible.
That's it. No complex calculations balancing good against bad cholesterol. No HDL goals to hit. The evidence consistently shows that lower LDL leads to fewer heart attacks and strokes, regardless of what HDL is doing.
This doesn't mean HDL is irrelevant: I still recommend exercise, weight loss, and not smoking because these will naturally raise HDL and are good for overall health. But these lifestyle changes work because they improve a patient's entire cardiovascular risk profile, not because they're boosting one specific number.
What I Tell My Patients Now
Despite all our sophisticated testing and different cholesterol subtypes, we've learned that managing cholesterol comes down to one simple goal: keep LDL low. I focus on statin therapy first, then add medications like ezetimibe or PCSK9 inhibitors if needed to get LDL to target levels.
The old story about balancing good and bad cholesterol was compelling, but science has a way of humbling our assumptions. Sometimes the most complex problems have surprisingly simple solutions. In this case, that solution is making sure the cholesterol that actually clogs arteries (LDL) stays as low as possible.
I tell my patients their HDL can take care of itself.
This article was written by Dr. Damian Rasch to help patients understand hypertension and its management. While comprehensive, it is intended for educational purposes only and does not constitute medical advice. Always discuss your specific situation with your healthcare provider.
Published by damianrasch.com
