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High HDL-C levels may not be protective against CVD in Black individuals
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High HDL-C levels may not be protective against CVD in Black individuals

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Cardiovascular Disease

Clarissa Chan, PharmD

A November 2022 study published in the Journal of the American College of Cardiology spotlights the racial disparities in current cholesterol treatment guidelines that are based on studies overrepresenting white patients.

“Our understanding of the cardiovascular risk factors stem mostly from white cohort studies like the Framingham heart study—the risk estimates or recommendations do not apply to everyone,” said Nathalie Pamir, PhD, at Oregon Health and Science University’s Knight Cardiovascular Institute in Portland, who was part of the study. “This is especially true for Black adults where their cardiovascular risk is underestimated.”

An image of multi-racial faces

The retrospective observational cohort study set out to investigate how high-density lipoprotein (HDL-C)—“good” cholesterol—contributes to CVD risk. Traditionally, low HDL-C levels were thought to increase CVD risk, and high HDL-C levels were thought to decrease CVD risk, but study authors found that low HDL-C levels may be associated with increased risk of coronary heart disease (CHD) in white adults, but not in Black adults. They also found that high HDL-C levels were not predictive of CHD risk in either racial group.

Study methods

The study population was based on REGARDS, a national longitudinal study of 30,239 Black and white community-dwelling adults 45 years and older.

Exclusion criteria included races other than Black or white, cognitive impairment, cancer treatment in the previous year, chronic conditions that prevent long-term study participation, inability to effectively communicate in English, and nursing home residence. Participants with prior CHD were excluded from the study, which lasted from 2003 to 2007.

Screening processes included an initial telephone interview to determine eligibility and obtain consent and later demographic information, including race (self-classified by participants) and medical history. An in-home assessment was conducted to determine baseline vital signs and labs via electrocardiogram, blood draw, and urinalysis.

The resulting cohort analysis included 23,901 participants, with 57.7% and 58.3% identifying as white and female, respectively. During the IRB-approved study by all participating institutions, follow-up phone calls were made to participants every 6 months to document CV events.

Outcomes included incident CHD defined as a definite or probable nonfatal myocardial infarction (MI) or CHD death after the baseline in-person visit or before December 31, 2017. CHD death was defined as definite or probable fatal MI within 28 days from event or death from cardiac signs or symptoms without noncoronary causes.


Both racial groups had comparable mean age, lipid profiles, smoking status, and diabetes and hypertension medication use.

Roughly 1,615 CHD events occurred in a median follow-up time of 10.7 years, with 41.1% and 45.5% occurring in Black and women participants, respectively. Black women experienced a higher incidence of CHD than white women, but there was no difference between men of both racial groups. CHD fatalities were higher in Black participants of both sexes than in white participants.

Based on lipid profiles, researchers found that for every 1 SD increase in low-density lipoprotein cholesterol (LDL-C) (34 mg/dL) and triglyceride (82 mg/dL) levels there was an associated increased CHD risk. Levels increased by 1 SD (16 mg/dL) in HDL-C were associated with decreased CHD risk in both races. Following statistical adjustment for clinical and behavioral variables, there was no association found between HDL-C levels and CHD risk in both races.

Low HDL-C levels were associated with poor CHD-free survival rates in white but not in Black participants, while high HDL-C levels were correlated with positive CHD-free survival rates in white but not in Black participants.

In unadjusted race-stratified models, lower HDL-C levels were associated with increased CHD risk in white but not in Black participants, while high HDL-C levels were associated with decreased CHD risk in both races. However, after clinical factor adjustments, low HDL-C was associated with increased CHD risk in white but not in Black participants, and high HDL-C did not provide a protective benefit for both races.


“These findings might change the conversation between the doctor and a patient with high HDL-C,” said Pamir. “Patients might no longer get the ‘pat on the back’ for having the protective effect of high HDL-C, because the doctor now might say ‘you have high HDL-C, but we don’t know what this means for your cardiovascular disease risk.’”

More studies are needed to focus on diverse ethnicities to assess the impact of traditional risk factors for each ethnicity. “When we build risk prediction algorithms, they need to apply to everybody,” said Pamir. ■

Editor’s note: This article is part of Pharmacy Today’s ongoing coverage of structural racism.



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