What is the best therapeutic approach for asymptomatic patients with zero to two cardiac risk factors, elevated LDL (>130-160 mg/dL), and high HDL (>60 mg/dL)? At what LDL would you treat the hyperlipidemia despite the high HDL?
—David Y. Kawashiri, MD, Beverly Hills, Calif. 

This is the question cardiologists are hearing more and more often: When does a high HDL counterbalance a high (or even borderline) LDL? The answer is not straightforward and depends on the other factors cited by Dr. Kawashiri, mainly the presence (or absence) of documented coronary artery disease (CAD) with or without symptoms and the profile of cardiac risk factors. If CAD is present, we all agree to treat LDL of 130-160. For the asymptomatic non-CAD individual with zero risk factors (including advanced age), however, I would probably not use statins at first but would try a dietary approach. In a patient older than 55 years who smokes or has diabetes or hypertension—alone or in combination—and especially with a positive family history, I would treat an LDL of 130 regardless of the HDL level. I realize that others would be more conservative. There is no clear-cut answer to this one.
—Peter F. Cohn, MD