Do you have high LDL or high total cholesterol? If you read my previous article about cheese, you may recall that these LDL or total cholesterol numbers alone are not reliable predictors of mortality from heart disease.
An NBC News piece went further to cite American science writer Gary Taubes who reported that the LDL and total cholesterol numbers have been such poor predictors of disease risk that early screening tests should have likely just tested for HDL and triglycerides and nothing else.
A 1977 NIH study — an early set of papers from the now legendary Framingham Heart Study — confirmed that high HDL is associated with a reduced risk of heart disease. It also confirmed that LDL and “total cholesterol” tells us little about the risk of having a heart attack, language that heart-disease authorities would downplay years later. Given this finding, as Gary Taubes writes in “Good Calories, Bad Calories,” we would have been better off to start testing for HDL — or even triglycerides — and nothing else.
A more nuanced view associates the risk of atherosclerosis and heart disease with the type of LDL particles. There are two patterns (also referred to as “phenotypes”) of LDL particles.
- Pattern A: large, fluffy LDL particles which are largely benign
- Pattern B: small, dense LDL particles which are more likely to oxidize and lodge themselves to arterial walls
Studies have long shown the impact of LDL particle size on disease risk. A 1988 study in the Journal of the American Medical Association documented the association between Pattern B (small, dense) particles and disease risk:
The LDL subclass pattern characterized by a preponderance of small, dense LDL particles was significantly associated with a threefold increased risk of myocardial infarction, independent of age, sex, and relative weight.
So why not test for LDL particle size? The tests are more expensive!
However, there is an answer. While testing for LDL particle size is more expensive today than commonly used cholesterol tests, a triglyceride / HDL ratio of 3.8 or higher can predict pattern B with high confidence. A 1997 Harvard Medical School study also confirmed the efficacy of triglyceride / HDL ratio to predict the risk of myocardial infarction.
Given the age of these studies, the use of HDL and triglycerides has become accepted practice in some circles, as described by Everyday Health.
According to Scott W. Shurmur, MD, the medical director of the cardiovascular center at Texas Tech University Health Sciences Center in Lubbock, Texas, the particle test should be used for people who have other risk factors for heart disease or stroke, such as a family history of heart disease at early ages. “At the same time, standard cholesterol tests like HDL and triglycerides provide similar information (and are less expensive), particularly if non-HDL cholesterol is incorporated into the assessment,” says Dr. Shurmur.
Unfortunately, there are no widely adopted standards today for metrics of triglyceride / HDL ratios in common clinical practice. Some researchers have provided guidelines, including Zone Diet creator Dr. Barry Sears who wrote:
How can you tell which type of LDL you have? All you have to do is determine your ratio of triglycerides to HDL cholesterol, which would be found as part of the results of your last cholesterol screening. If you ratio is less than 2, you have predominantly large, fluffy LDL particles that are not going to do you much harm. If your ratio is greater than 4, you have a lot of small, dense LDL particles that can accelerate the development of atherosclerotic plaques – regardless of your total cholesterol levels.
Still, patients who view their standard lab test results will notice that standard lab results list other ratios including Total Cholesterol / HDL and LDL / HDL ratios, but they do not list Triglyceride / HDL ratios.
(TG/HDL = 138/83 = 1.7)
So why aren’t Triglyceride / HDL ratios more in use, or why aren’t LDL particle sizes discussed more often in the doctor’s office? After all, most of the research cited in this blog article is decades old!
Frequent readers of this blog know my skepticism around a lot of Western Medicine. Most continuing education for doctors is sponsored by pharmaceutical companies who have commercial interests in promoting use of lab numbers that their drugs can lower! According to an academic paper titled “Statins Do Not Decrease Small, Dense Low-Density Lipoprotein:”
Our study suggests that statin therapy—whether or not recipients have coronary artery disease—does not decrease the proportion of small, dense LDL among total LDL particles, but in fact increases it, while predictably reducing total LDL cholesterol, absolute amounts of small, dense LDL, and absolute amounts of large, buoyant LDL.
In other words, drug companies likely suppress the information about LDL particle sizes because their drugs preferentially target the benign “Pattern A” particles over the more harmful “Pattern B” particles!
My opinion: Before going on cholesterol lowering drugs, take a look at your triglyceride / HDL ratio. You may have “Pattern A” LDL particles and be at lower risk of heart disease than your LDL or total cholesterol numbers suggest.
Thanks, very interesting.
So, if my triglyceride level is 123 and my HDL is at 49 , the ratio is around 2.5— which is okay? Even though my LDL is at 192 ?
Your triglycerides are normal, and so are your HDLs. I think most doctors would recommend your taking a test for lipid subfractionalization by ion mobility. I did this in Germany, and my results showed “pattern A” with a high relative number of larger “fluffy” particles, and a small relative number of smaller “dense” LDL particles. The tests are offered in the US, too.
https://www.questdiagnostics.com/home/physicians/testing-services/condition/cardiovascular/cardio-iq-ion-mobility.html
The most recent Cleveland Heart Lab Cardio IQ test panel has my triglycerides at 103 and my HDL at 49, a ratio of about 2.1-1. Unfortunately it also shows I have far too many small lipid particles. Both LDL and HDL particles are too small according to the test results. I had 1909 LDL particles which is far too high according to their test. Small LDL, and medium LDL were both at 490, far above the maximums considered satisfactory. Large HDL came back with a number of 3881, which is far too low according to their test.
Lipoprotein(a) was a bright spot. I was only at 15 nmol/L according their test, much lower than the maximum of 75 considered optimal. What exactly should I make of these results?
You are a pattern B. For a complete picture I would suggest doing an inflammation panel by Cleveland heart labs. Also 9p21 and Apo B test.
It’s my understanding from research I’ve seen, that pattern B LDL has free cholesterol bound to the outside of its ‘shell’ but when that cholesterol becomes esterified, it gets drawn into the shell, swelling the pattern B LDL to become large fluffy pattern A.
IF this is so, the question in my mind is how to deliberately trigger that esterification?
I recently ran an expensive Cardio IQ test and discovered that I have a huge problem with small, dense LDL. The same test showed very low levels of Lipoprotein (a). The results of recent cardiac calcium scoring tests and Lp-PLA2 blood tests show I need to be very concerned because of increasing arterial inflammation and greatly increased calcium deposits. I am currently running HDL numbers in the low to mid forties and triglycerides in the 170-200 range with total LDL usually over 200.
I would suggest finding a provider that is associated with the BaleDoneen method. Look at their website. They have been treating this condition for the last 15 years with huge success. Their specialty.
Second that on the Baledoneen method. Their forte.
With an HDL of 97 and triglycerides of 50, I guess a forumula determined LDL of 161 should not be too worrisome?
I would be more concerned with the number and size of LDL particles. If you have large numbers of small LDL particles, that would be of concern. If they are mostly large particles, I wouldn’t be concerned at all. Cleveland Heart Lab’s lipoprotein fractionation tests or Labcorp’s NMR lipoprofile test panel would tell you about the number and size of LDL particles.
Cholesterol levels are the wrong thing to test for. You can be harmed by having too many LDL particles, too many small LDL particles in particular, or too many oxidized particles.
Thank you!
According to my recent lab results , Cardio IQ, I have LDL pattern B. LDL small and medium lipoprotein fractionation, ion mobility are both in the moderate risk category while HDL large is well within the high risk category. Can you direct me to any articles or information on what I can do to lower my risk?
Can a person have both pattern A and pattern B LDL’s?
I’m looking more deeply than just whether they classify me as pattern A or pattern B. They use somewhat arbitrary dividing lines for classification. I’m still overweight but less than I used to be. My apolipoprotein B levels are still too high. My Lp-PLA2 levels remain too high. Just getting labeled by Cleveland Heart Lab as pattern A isn’t good enough.
The answer is no. You’re either a patter A or B
Hi, My latest test (19th Jan) shows LDL= 239, HDL= 74, Triglyceride=80, Total Cholesterol=329. My doctor wants to immediately put me on statins (Lipitor). I tried to argue that a) my TG:HDL ratio at 1.08 was ideal and b) I believe statins do more harm than good. To no avail – I was told not to believe what I read in tabloid newspapers – although I have done quite a bit of serious research. Am I or my doctor right/wrong. If I am right then do I need to take any action at all?
Have you ever been to the YouTube website of cardiologist Dr. Ford Brewer? He would argue that conventional doctors prescribe the wrong statins for the wrong reasons and in doses that are much higher than what is often needed. According to him, Crestor and Livalo are better choices that Lipitor. He says that statins should be prescribed to reduce arterial inflammation which is the real issue, not cholesterol numbers.
Most conventional doctors do not run tests for LDL particle numbers or Lp(a). Neither do they run tests for inflammation markers such as LP-PLA2. Such tests provide far better information than just running a cholesterol panel.
I have a total cholesterol level or 237 with 123 triglycerides and 70 hdl and 142 ldl. So using that triglycerides/hdl ratio formula I got <2 so it means I have type A?
No, you need a fractionation test.
Eventhough I am clearly a Pattern A patient, I would like to know If having an increasing pattern in LDL levels should be of concern (or at what point should having fluffy and few ldl particles is not enough).
In a Lab Corp test done in Sept 2020 I had total cholesterol at 280, LDL-P at 1669, LDL -C at 171 and HDL-C at 75. Luckily small LDL -P is 101 and LDL size is 22.6. However, in a regular lipid study Ldl-C increased from to 207.
my recent lab corp results have my total cholesterol at 190, Triglycerides at 58, HDL at 55, vLDL at 11, LDL at 124. o my triglycerides to HDL is almost 1. Would it be a fair assumption that my LDL could be mostly type A ??
So for the past three years I’ve been eating healthier and healthier, I have an active job, I exercise for fun. I’m normal weight with perfect glucose numbers but still my LDL is going up!
My doctor wants me on Lipitor and says I may have Familia Hyperlipidemia but according to this and other sources I may be very very low risk.
My most recent test on 2/24/21 is as follows.
Total: 268
HDL: 55
Triglycerides: 66
LDL: 196
If my math is right 66/55 is only 1.2
I’m a lil skeptical but scared at the same time. I’m going to schedule a CAS soon to see where I’m at, bit what other tests are recommend?
Thanks for the blog!
You need to get a fractionation test from Cleveland heart lab. That will pretty much break down everything.
Hello,
my LDL was always high, no matter how healthy my life was and how much time I spend with cardio and in the gym. In the past months I changed my life from healthy to super healthy… even more cardio, even less alcohol, walking 25 kms each week alone to the office and back, no meal after 4 p.m., low carb, and lost another 10 pounds. Feel better and powerful – both physically and mentally than ever. My HDL raised by 10 %, but my LDL by more than 15! This starts to drive me crazy… expected declining or at least constant LDL.
Triglycerides/HDL ratio is 0.36, LDL/HDL ratio 2.6, age 54, 1.75 m, 86 kg, lots of muscles due to weight lifting three times a week
Any comments on these facts/numbers? Am I a medical miracle at the end of the day?
TIA for any feedback!
0.36 is good… maybe too good… this is based on mmol/l. But the scales of cholesterol and triglycerides are different. In mg/dl ist should be around 0.8, which is still good..
Your triglycerides are in the basement or you have unusually high HDL with that kind of ratio. Have you ever run Lp-PLA2? That test measures arterial inflammation.
both of your statements are true. I believe the trig. are low due to low carb diet, combined with interval diet. HDL may be high due to lot of cardio activity. Thx for the hint on Lp-PLA. Will do some research on this. Later
Ekki: Most of your numbers are genetic . Of course what you eat and lifestyle influence your number a bit. But gotta look at you family. Get genetic testing from Cleveland heart lab for more information.
I have not had genetic testing done thru Cleveland Heart Lab. For me I have noticed that I have a big problem with excessive numbers of small dense LDL particles. My last test for high-sensitivity C-reactive protein had me at 0.5 which is very good, but I have never gotten my Lp-PLA2 down to 123. According to that test I’m high risk. A few years ago my Hemoglobin A1C was 5.8 which is too high. The most recent test has me at 5.3 which is far better.
A few years ago, my blood pressure averaged something in the ballpark of 135/82. Today the average is about 120/72. I’m 68 years old and male. I have made good progress in some areas but not others. I do not take any prescription drugs. I have had some success reducing my weight thru time-restricted eating but it really takes a lot of discipline to maintain it. I have removed liquid calories from my diet.
My Lipid panel read this way on the following dates
2/2020 total cholesterol 203, hdl 55, try 48, LDL 138. Try/Hdl =0.87
11/2020 total cholesterol 248, hdl 89, try 56, LDL 150 Try/ Hdl=0.62
It appears have pattern A. There was an increase in LDL and HDL in part due to dietary changes, supplements and workouts.
Good afternoon – My recent blood results are shown below – are you able to tell me if I am pattern A or B please? Many thanks in advance.
Serum cholesterol level 5.7 mmol/L
Serum triglyceride levels 2.47 mmol/L [0.3 – 1.8]
Above high reference limit
Serum HDL cholesterol level 1.21 mmol/L
Serum LDL cholesterol level 3.36 mmol/L
Serum cholesterol/HDL ratio 4.7
Serum non high density lipoprotein cholesterol level 4.49 mmol/L
To me getting classified as either pattern A or pattern B is somewhat arbitrary because it can depend on where the boundary gets drawn. With respect to LDL I would worry a lot more about the number of particles than how much LDL cholesterol is being transported. That takes a more expensive lipoprotein fractionation test to determine that. Also have you ever been tested for Lp(a)? Most conventional doctors fail to run this very important test. It’s largely dictated by genetics. If you have high levels on Lp(a) you are at a huge disadvantage compared with those who don’t. Many people who have high levels of Lp(a) have very early heart attacks. It’s sad but true. This condition can be treated but thanks to the ignorance and improper training of most conventional doctors, it often goes undiscovered until it’s too late.
I recently had an advanced lipid panel, cardio IQ test from quest diagnostics. Trying to better understand the results. Any help/information would be greatly appreciated. Majority of my numbers are high risk on reference range, but still pattern A. Not sure if I’m reading these results correctly. Should I be concerned?
Total 242. HDL 62. Triglycerides 53. LDL 165.
Chol/HDLC ratio 3.9
Non HDL cholesterol 180
LDL particle number 2050. LDL small 248. LDL medium 409. HDL large 5664.
LDL pattern A
LDL peak size 224.2 Angstrom
Apolipoprotein B 125
Lipoprotein (a) 142
There are two things I quickly noticed that I would be concerned about if I were you. Your LDL particle number is too high. Your Lp(a) is also too high. Lp(a) is largely dictated by genetics. To some extent the levels can be modified. But no matter what you do, the bad gene that you probably have will always create an added additional risk for heart attacks and strokes that you would not have if too many LDL particles were the only major issue. If at all possible try to get on a prescription drug or whatever is needed to bring your Lp(a) levels down to a much better number. I hate to tell this, but in general elevated Lp(a) is a far worse problem than too many LDL particles, although both contribute to problems.
Thanks for the information Kelly. Much appreciated. Any suggestions on diet? Should I take an aspirin to lower LP(a) or any other method that will help lower the LP(a) number?
I honestly don’t know which method is best. I have seen different sources touting vitamin C, niacin, and certain prescription drugs. I have heard that high intake of animal protein may increase Lp(a) levels. I honestly don’t know which method of control is best. Unlike you I have very good genes with respect to Lp(a) and can just ignore it. The highest number I have ever had on a Lp(a) test is only 29. The lowest is 11.
Many people who have high levels of Lp(a) suffer deadly heart attacks in their 40s or 50s. One person that might be able to help you is Dr. Ford Brewer who has a Youtube website.
Thanks. I will look into that
I’ve been treating Lp(a) for years. The most successful treatment I’ve found is
EXTENDED RELEASE Niacin – Niaspan (rx). This is NOT the same as SLOW RELEASE.
Have your PCP or cardiologist prescribe this for you. They might say it does not work due to a paper put out by JAMA about a drug that a pharmaceutical company tried to develop by attaching another molecule to the Niacin so people would not flush, and it did not work. So the conclusion was the niacin does not work. But they failed to mention that changing the molecule did not work.
Thanks for the response. All this is information is so helpful. I know dr brewer is a big fan of niacin as well. I will have to reach out to my pcp to prescribe some. Either of you ever hear of a CIMT test? Thoughts on it if you have. Is it worth it for possible blockage detection, etc…
I have never actually had a CIMT test done. Lifeline Screening has a mediocre version of this type of test which focuses on blood flow issues rather than focusing on how thick the arterial deposits are. I have previously had the mediocre Lifeline Screening test done. One problem lies in the fact that many people who suffer deadly heart attacks or strokes don’t have a blood flow problem but they have sufficient arterial deposits to cause inflammation. One problem with the CIMT test lies with its limited availability and higher cost. It’s definitely better than the mediocre Lifeline Screening version as far as the information it provides.
One type of test that I have had run several times is a cardiac calcium scoring test. While it’s true that it only detects hardened calcified deposits and can’t see soft deposits, it’s usually a good bet that if you have substantial hardened deposits you also have substantial soft deposits. The soft deposits are what most often cause heart attacks and strokes.
Yes, the CIMT is not done by every radiology company . Most will tell you if you have “plaque” in the arteries. They do not comment on the soft plaque. Soft plaques is very important.
Thanks so much. Awesome information and knowledge from both of you.
I did have a coronary artery calcium CAC test done a couple months back and it was 134 score. All in the LAD artery. Any thoughts on that? Good, bad etc.. considering how high my LP a score was does that mean I’m in a better spot with a 134 CAC score for overall heart problems?
The LAD artery is usually the one most affected. That artery is often called the “widow-maker” artery because it’s the one that most often causes fatal heart attacks. Calcification is actually a body defense mechanism against arterial inflammation. It’s been a little over a year since my last calcium scoring test. I was at 172 with most but not all of the calcium in the LAD artery.
The Youtube website of Ivor Cummins is a very strong advocate of the calcium scoring test. There are advantages and drawbacks to all kinds of tests. In my particular case it’s all roses when you run the C-reactive protein test but the situation is less favorable when you run the Lp-PLA2 test. I have never been able to get my Lp-LPA2 down to the level Quest considers optimal, but C-reactive protein is a different story.
C-reactive protein suffers from the problem that it measures inflammation anywhere regardless of what it’s related to. Lp-PLA2 is specific to the blood vessels and arteries. The latter actually measures a specific enzyme which the body produces to attack arterial deposits.
Do you suggest getting a Lp-LPA2 test considering how high my other numbers are on lp a and particle sizes ? Is it a good marker for cardiovascular risk/disease?
I know someone that had a 900 score on CAC test. They went to a cardiologist and did a stress test, echocardiogram etc… and cardiologist told the individual after all the running/tests they did that they were fine and nothing to worry about. I assume it all depends on the individual and what tests works best for them.
As Dr. Ford Brewer and others have correctly pointed out, stress tests are not reliable. The famous NBC News “Meet the Press” moderator, Tim Russert, passed a stress test a few days before suffering a fatal heart attack in 2008. He had taken a CAC a decade earlier which had him at a score of 210. Most likely it would have been much higher close to the day of his fatal heart attack but he didn’t get a repeat CAC test then. Lp-PLA2 is probably a far better test for measuring arterial inflammation than C-reactive protein. But there is no single test that is 100% correct all the time.
In general, high Lp(a) is something to really worry a lot about because of statistics on who most often gets early age heart attacks. There is something about that specific particle which makes it far more dangerous than a standard LDL particle. Although I do not have a problem with Lp(a), I have another issue I have to be concerned about: excessive numbers of small, dense LDL particles. We all have different issues, some of which are heavily influenced by our genes.