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The Good, the Bad and the Ugly: a new way to look at Cholesterol and heart disease.


Heart disease has been the #1 cause of death in America.  Many of these people could have lived longer lives had they heeded the signs that they were at risk for heart disease.  Helping patients understand their risk factors has been a focus of health professionals over the years.  A study conducted by the Danish Medical Research Council and published in the Journal of the American College of Cardiology sheds some light on a new way to gauge a patients’ the risk factors.

Conventional wisdom regarding a patient’s risk of developing heart disease has been to characterize cholesterol using three measures and one ratio:   

1. Total Cholesterol- as low as possible, but ideally under 200 mg/dl

2. High Density Lipoprotein (HDL)- as high as possible, ideally above 40 mm/dl

3. Low Density Lipoprotein (LDL)- as low as possible, preferably under 100mm/dl

4. The ratio between Total Cholesterol and HDL- as low as possible; ideally below 5:1

The Danish study uses another measure of cholesterol that is often overlooked and comes up with a more effective way to calculate cardiac risk than the standard methods listed above.   

A careful analysis of blood cholesterol levels will show that there is a difference between total cholesterol and the sum of LDL and HDL; this remaining cholesterol level is called the “residual cholesterol” level.  The “residual cholesterol” (RC) which is also characterized as “Ugly cholesterol”, is made up of remnants of LDL and HDL cholesterol in the blood stream.  

The study found that levels of RC alone and the ratio of RC to HDL were far more effective methods for gauging patients’ risk factors for heart disease than LDL alone.

Calculating this ratio is simple.  Take the total cholesterol, subtract LDL and HDL.  Divide the result by HDL and you’ll get the ratio.  Ischemic heart disease risk can be evaluated using the table below:

Ischemic heart disease risk RC/HDL ratio

Lowest risk quintile < 0.2

Second lowest risk quintile 0.2 – 0.3

Mid-level risk quintile 0.3- 0.5

Second highest risk quintile 0.5 – 0.8

Highest risk quintile > 0.8


The study concludes with the statement that a 39 mm/dl increase in nonfasting remnant cholesterol is associated with a 2.8-fold causal risk for ischemic heart disease, independent of reduced HDL cholesterol.

1: J Am Coll Cardiol. 2013;61(4):427-436. doi:10.1016/j.jacc.2012.08.1026