For decades, high-density lipoprotein (HDL) cholesterol, commonly known as “good cholesterol,” has been considered a reliable marker for predicting heart disease risk. However, a groundbreaking study funded by the National Institutes of Health (NIH) suggests this long-held belief may not hold true across all racial and ethnic groups.

Published in the Journal of the American College of Cardiology, the research highlights that while low levels of HDL cholesterol predict increased heart disease risk for white adults, the same is not true for Black adults. Additionally, higher HDL levels were not consistently linked to reduced cardiovascular disease risk in either group.

Key Findings from the Study

The study analyzed data from 23,901 adults who participated in the Reasons for Geographic and Racial Differences in Stroke Study (REGARDS) over 10–11 years. Key insights include:

1. Low HDL and Cardiovascular Risk:
   • For white adults, lower HDL cholesterol levels predicted higher cardiovascular disease risk.
   • For Black adults, this association was not observed.
2. High HDL Levels Offer No Universal Benefit:
   • Higher-than-optimal HDL levels did not significantly reduce heart disease risk in either Black or white adults.
   • This finding challenges the assumption that simply having high HDL cholesterol is protective.
3. Broader Risk Factors Remain Valid:
   • Increased LDL cholesterol and triglycerides were linked to modestly higher heart disease risks across both groups.

Revisiting the Role of HDL Cholesterol

The study suggests a shift in focus from the quantity of HDL cholesterol to its quality and function. Researchers propose that HDL’s ability to transport and eliminate excess cholesterol from the body might play a more critical role in cardiovascular health than previously thought.

Sean Coady, deputy branch chief of epidemiology at the National Heart, Lung, and Blood Institute (NHLBI), emphasized the need for a deeper understanding of lipid metabolism and how factors like race and ethnicity influence cardiovascular outcomes.

Implications for Cardiovascular Risk Calculators

Current cardiovascular disease (CVD) risk calculators often include HDL cholesterol levels as a key metric. However, this study raises concerns about their accuracy, particularly for Black adults.

Dr. Nathalie Pamir, the study’s senior author, advocates for revising risk-predicting algorithms to ensure they are inclusive and reflective of diverse populations. “Risk factors for heart disease cannot be limited to one race or ethnicity. They need to apply to everyone,” she stated.

Why This Matters for Doctors

1. Rethink HDL’s Predictive Role: Recognize that HDL cholesterol may not uniformly predict heart disease risk across all racial and ethnic groups.
2. Focus on Comprehensive Assessments: Incorporate additional biomarkers and patient history into risk evaluations for more accurate predictions.
3. Encourage Inclusive Research: Support studies involving diverse populations to ensure guidelines apply to everyone.

Looking Ahead

The study underscores the importance of personalized and equitable approaches to cardiovascular care. By understanding HDL cholesterol’s nuanced role and improving risk assessment tools, healthcare providers can better predict and manage heart disease for all patients.

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