A 58-year-old man with stable coronary artery disease, hypertension, tobacco use, obesity, and a sedentary lifestyle presented to our institution for routine follow-up. He did not have any ischemic or heart failure symptoms. His daily medications included an aspirin, hydrochlorothiazide (Microzide), an angiotensin-converting enzyme inhibitor, a statin, and a β-blocker. His blood pressure was 118/70 mm Hg, his heart rate was 65 beats per minute, and his body mass index was 38 kg/m². The patient’s fasting blood tests showed the following: glucose, 90 mg/dL; low-density lipoprotein (LDL) cholesterol, 59 mg/dL; high-density lipoprotein (HDL) cholesterol, 32 mg/dL; and triglycerides, 148 mg/dL. He asked whether he should be concerned about his low HDL cholesterol level.

A low HDL cholesterol level does confer an increased risk of coronary events, even in the setting of LDL cholesterol levels < 60 mg/dL. Exercise, weight loss, and smoking cessation should be recommended as first-line interventions, as each has been demonstrated to increase HDL cholesterol levels and improve cardiovascular outcomes. Dietary modification with increased intake of n-3 polyunsaturated fat may achieve these goals as well. For high-risk patients with persistently low HDL cholesterol levels despite lifestyle changes, niacin or fibrates may be considered in the absence of contraindications. Further studies are needed before pharmacotherapy above and beyond current aggressive medical treatment can be recommended to patients.