title: Non-high-density lipoprotein cholesterol, guideline targets, and population percentiles for secondary prevention in 1.3 million adults: the VLDL-2 study (very large database of lipids).
abstract: OBJECTIVE
  This study sought to examine patient-level discordance between population percentiles of non-high-density lipoprotein cholesterol (HDL-C) and low-density lipoprotein cholesterol (LDL-C).
  
  
  BACKGROUND
  Non-HDL-C is an alternative to LDL-C for risk stratification and lipid-lowering therapy. The justification for the present guideline-based non-HDL-C cutpoints of 30 mg/dl higher than the LDL-C cutpoints remains largely untested.
  
  
  METHODS
  We assigned population percentiles to non-HDL-C and Friedewald-estimated LDL-C values of 1,310,440 U.S. adults with triglyceride levels <400 mg/dl who underwent lipid testing by vertical spin density gradient ultracentrifugation (Atherotech, Birmingham, Alabama) from 2009 to 2011.
  
  
  RESULTS
  LDL-C cutpoints of 70, 100, 130, 160, and 190 mg/dl were in the same population percentiles as non-HDL-C values of 93, 125, 157, 190, and 223 mg/dl, respectively. Non-HDL-C values reclassified a significant proportion of patients within or to a higher treatment category compared with Friedewald LDL-C values, especially at LDL-C levels in the treatment range of high-risk patients and at triglyceride levels ≥150 mg/dl. Of patients with LDL-C levels <70 mg/dl, 15% had a non-HDL-C level ≥ 100 mg/dl (guideline-based cutpoint) and 25% had a non-HDL-C level ≥ 93 mg/dl (percentile-based cutpoint); if triglyceride levels were 150 to 199 mg/dl concurrently, these values were 22% and 50%, respectively.
  
  
  CONCLUSIONS
  There is significant patient-level discordance between non-HDL-C and LDL-C percentiles at lower LDL-C and higher triglyceride levels, which has implications for the treatment of high-risk patients. Current non-HDL-C cutpoints for high-risk patients may need to be lowered to match percentiles of LDL-C cutpoints. Relatively small absolute reductions in non-HDL-C cutpoints result in substantial reclassification of patients to higher treatment categories with potential implications for risk assessment and treatment.
authors: Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio; Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland. Electronic address: elshazm@ccf.org.
authors: Mohamed B
authors: MB
authors: Elshazly
authors: Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland.
authors: Seth S
authors: SS
authors: Martin
authors: Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland.
authors: Michael J
authors: MJ
authors: Blaha
authors: Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland.
authors: Parag H
authors: PH
authors: Joshi
authors: Department of Preventive Cardiology, CGH Medical Center, Sterling, Illinois; University of Illinois College of Medicine, Peoria, Illinois.
authors: Peter P
authors: PP
authors: Toth
authors: Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland.
authors: John W
authors: JW
authors: McEvoy
authors: Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland.
authors: Mohammed A
authors: MA
authors: Al-Hijji
authors: Atherotech Diagnostics Lab, Birmingham, Alabama.
authors: Krishnaji R
authors: KR
authors: Kulkarni
authors: Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland.
authors: Peter O
authors: PO
authors: Kwiterovich
authors: Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland.
authors: Roger S
authors: RS
authors: Blumenthal
authors: Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland.
authors: Steven R
authors: SR
authors: Jones
mesh_terms: D002318:Cardiovascular Diseases / Q000097:blood / Q000517:prevention & control*; D008078:Cholesterol, LDL / Q000097:blood*; D005260:Female; D006801:Humans; D000960:Hypolipidemic Agents / Q000627:therapeutic use*; D008297:Male; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D055502:Secondary Prevention / Q000379:methods*; D016896:Treatment Outcome
chemical_list: D008078:Cholesterol, LDL; D000960:Hypolipidemic Agents
keywords: CVD; HDL-C; LDL cholesterol; LDL-C; VAP; VLDL; cardiovascular disease; discordance; high-density lipoprotein cholesterol; lipids; low-density lipoprotein cholesterol; non–HDL cholesterol; percentiles; secondary prevention; vertical auto profile; very-low-density lipoprotein cholesterol