What is a “good” cholesterol level?

Warren, a 56-year old accounting manager at a manufacturing plant, recently came to my office and asked, "My doctor said my LDL cholesterol was 141. He said that's too high. But I've talked this over with some of my co-workers, and they tell me that they had LDL cholesterols a lot higher than that. Is my LDL really too high?"

At first blush, it sounds like a straightforward question: Either cholesterol is too high and you'll have heart disease in your future, or it's low and you won't. Period.

Not so fast. There are a number of issues to factor into you and your doctor's thinking and decision making about cholesterol. Unfortunately, it's not just a matter of just too high or too low.

By current conventional advice (the consensus statement as issued by the National Cholesterol Education Panel via the Adult Treatment Panel-III, or ATP-III, the most recent and broad applied guidelines followed by most doctors), the following general scheme is advised (see below). You will notice that the principal focus of the guidelines is LDL cholesterol--LDL cholesterol is the number one determinant of heart disease risk, it is the number one reason drugs are prescribed; all else follows LDL.

ATP III Consensus Guidelines: Classification of LDL, Total, and HDL Cholesterol (2001)

LDL Cholesterol (mg/dl)

<100 Optimal

100-129 Near optimal/above optimal

130-159 Borderline high

160-189 High

>190 Very high

Total Cholesterol (mg/dl)

<200 Desirable

200-239 Borderline high

>240 High

HDL Cholesterol (mg/dl)

<40 Low

>60 High

ATP-III provides for adjustment of target LDL cholesterol based on risk factors in a specific individual. They define "risk factors" as:

Cigarette smoking

Hypertension (BP>140/90 mmHg or on antihypertensive medication)

Low HDL cholesterol (<40 mg/dL)

Family history of premature CHD (CHD in male first degree relative <55

years; CHD in female first degree relative <65 years)

Age (men >45 years; women >55 years)

LDL cholesterol targets are adjusted:

If coronary heart disease or "risk equivalents" are present (e.g., diabetes or other forms of atherosclerotic disease such as aortic aneurysm or carotid disease causing symptoms) LDL target <100 mg/dl

Multiple (2+) risk factors LDL target <130 mg/dl

Zero to one risk factor LDL target <160 mg/dl

More recently, in 2004, the ATP-III LDL target was optionally reduced to 70 mg/dl in people felt to be at particularly high-risk, such as recent heart attack survivors, smokers, or people with combined diabetes and heart disease, based on the favorable outcomes of some of the clinical trials of more intensive LDL cholesterol reduction by statin drugs.

From Third Report of the Expert Panel on Detection, Evaluation, and Treatment of the High Blood Cholesterol in Adults (Adult Treatment Panel III): Executive Summary, 2001

What the ATP-III guidelines and your doctor probably won't tell you: