Should we change our lipid management strategies to focus on non-high-density lipoprotein cholesterol?

Despite aggressive low-density lipoprotein cholesterol lowering, patients continue to be at significant risk of cardiovascular events. Assessment of non-high-density lipoprotein cholesterol (non-HDL-C) provides a measure of cholesterol contained in all atherogenic particles. In the third Adult Treatment Panel guidelines, non-HDL-C was introduced as a secondary target of therapy.

A combined post-hoc analysis of data from two prospective, randomized trials assessing the role of statins in patients with established coronary heart disease showed that on-treatment levels of non-HDL-C were more closely associated with cardiovascular outcomes than levels of low-density lipoprotein cholesterol. A recent meta-analysis of the relationship between non-HDL-C reduction and coronary heart disease risk showed that most lipid-modifying drugs used as monotherapy have a 1 : 1 relationship between percentage non-HDL-C lowering and percentage coronary heart disease reduction. In the European Prospective Investigation Into Cancer and Nutrition-Norfolk prospective population study (n = 21,448), participants with high non-HDL-C levels were at increased coronary heart disease risk independently of their low-density lipoprotein cholesterol levels.

Because non-HDL-C appears to be superior for risk prediction beyond low-density lipoprotein cholesterol, future guidelines should emphasize the importance of non-HDL-C for guiding cardiovascular prevention strategies. There is an increased need to have non-HDL-C reported on routine lipid panels, especially because it would be at no added cost.