HDL-cholesterol as a marker of coronary heart disease risk: the Quebec cardiovascular study

Background: Primary as well as secondary prevention trials have shown the r elevance of lowering LDL-cholesterol to reduce coronary heart disease (CHD) risk. However, although the association between LDL-cholesterol and CHD is well recognized, there is a considerable overlap in the distribution of pl asma LDL-cholesterol levels between CHD patients and healthy subjects. The objective of the present review article is to use data from the Quebec card iovascular study to demonstrate that in men, a low HDL-cholesterol may be e ven more of a risk factor and a target for therapy than a high LDL-choleste rol. Methods and results: Results of the Quebec cardiovascular study, a pro spective study of 2103 middle-aged men followed for a period of 5 years, ha ve confirmed results of previous studies in showing that plasma HDL-cholest erol concentration was an independent predictor of a first ischemic heart d isease (IHD) event which included typical effort angina, coronary insuffici ency, nonfatal myocardial infarction and coronary death. In addition, a red uced plasma HDL-cholesterol concentration was found to have a greater impac t than raised LDL-cholesterol on the atherogenic index (total cholesterol/H DL-cholesterol ratio), this ratio being the best variable of the traditiona l lipid profile for the prediction of IHD events in the Quebec cardiovascul ar study. However, a low HDL-cholesterol concentration is not often observe d as an isolated disorder but also includes hypertriglyceridemia, elevated apo B concentration, and an increased proportion of small, dense LDL partic les. These abnormalities are features of an insulin resistant-hyperinsuline mic state resulting from abdominal obesity. Conclusions: It is therefore re commended that we need to go beyond LDL-cholesterol measurement lowering th erapy for the optimal management of CHD risk. Raising plasma HDL-cholestero l through weight loss and a healthy diet, by an increased physical activity and, if required, by proper pharmacotherapy is therefore a legitimate ther apeutic target for the optimal prevention of CHD in a large proportion of h igh risk patients. (C) 2000 Elsevier Science Ireland Ltd. All rights reserv ed.