Specialized lipid testing, sometimes called lipoprotein particle testing, is ordered by doctors to further check risk status.  Doctors look for the presence of a “discordance” between the LDL cholesterol level on a standard lipid profile and risk.  Another test to assess this is the ApoB (apolipoprotein B) level.  Discordance occurs almost always if someone has high triglycerides, and is typically seen in people who are overweight or have diabetes.

 

What do we mean by “discordance?”

Discordance occurs when the LDL cholesterol does not estimate risk as well as other lipid measures.  This can occur in up to 20% of people.  Most of these people are overweight or obese or have diabetes.

 

Should individuals with familial hypercholesterolemia (FH) get specialized lipid testing?

The short answer is no.  In FH there is almost never discordance between LDL cholesterol levels and risk.  Additional testing that helps in risk stratification for FH includes genetic testing and measuring Lp(a). If you want to learn more, read.on.

 

What causes discordance?

Triglycerides and cholesterol are carried around in the blood on particles that combine proteins and fat. VLDL particles carry a lot of triglyceride and LDL particles carry a lot of cholesterol.  When triglycerides are high, LDL particles have less cholesterol (for many reasons) and thus, become smaller. When this happens, and because LDL particles are smaller, there are more LDL particles at any given level of LDL cholesterol. Since LDL particles cause atherosclerosis, studies have shown that the more LDL particles that are present, the higher the risk.  This higher risk may also be measured as a higher non-HDL cholesterol (a measure of all the lipid particles combined other than HDL), higher apolipoprotein B (apoB) level, or is also called excess “small LDL.”

 

Does discordance occur in FH?

This “discordance” almost never occurs in familial hypercholesterolemia.  Patients with FH usually do not have high triglycerides.

In FH, the LDL cholesterol is an accurate reflection of risk and total particle number.  You should remember that all LDL particles will cause plaque to build up in the arteries regardless of size. Patients with FH have more LDL particles than those without FH. No LDL particle is good for you. It remains controversial whether or not the smaller particles cause more atherosclerosis than bigger particles.

 

 

Cholesterol numbers: what do my test results mean?
Cholesterol Results

Your body needs cholesterol for healthy functioning of cells. However, too much cholesterol greatly increases your risk of heart disease, including heart attacks and strokes. There are no symptoms for high cholesterol, so the only way to know if you have "too much" is through a cholesterol test, also called a lipid panel or profile.

So, what do the results of a cholesterol test mean for your health? What is total cholesterol, LDL, HDL... ? It is important to not only look at the overall cholesterol number but to know your numbers for all types of cholesterol.

Cholesterol Numbers

HDL vs LDL cholesterol diagram

What are the types of Cholesterol?

There are two types of cholesterol: low density lipoprotein (LDL) and high density lipoprotein (HDL).

LDL is considered the “bad” cholesterol, because it contributes to the fatty build ups in arteries.

HDL is considered the “good” cholesterol which when healthy can help protect against heart attack and stroke. It is better to have higher levels of HDL cholesterol and lower levels of LDL cholesterol.

There are also triglycerides, which is another type of fat in the bloodstream, that are also tied to heart disease.

Let's talk numbers

Total Blood Cholesterol Level:

High risk: 240 mg/dL and above

Borderline high risk: 200-239 mg/dL

Desirable: Less than 200 mg/dL

 

LDL Cholesterol Level:

High risk: 190 mg/dL and above

Desirable: Less than 100 mg/dL and less than 70 mg/dL if you have heart disease

 

HDL Cholesterol Level:

High risk (Men): Less than 40 mg/dL

High risk (Women): Less than 50 mg/dL

 

Triglyceride Level:

Very high risk: 500 mg/dL and above

High risk: 200-499 mg/dL

Borderline high risk: 150-199 mg/dL

Normal: Less than 150 mg/dL

Cholesterol builds up in the arteries and causes heart disease
I have very high LDL cholesterol. What should I do now?

For LDL-cholesterol, the general principle is that the "lower is better." According to the American College of Cardiology and American Heart Association's cholesterol management guidelines, individuals should have an LDL cholesterol under 100 mg/dL and under 70 mg/dL if they already have heart disease.

Are there ways to lower my cholesterol?

There are several considerations for lowering one’s cholesterol. Changes in one’s diet, exercise and personal habits can all be adjusted to help reduce your cholesterol levels. Learn more.

I eat healthy and exercise, but l still have high cholesterol. What can I do?

If you have an LDL cholesterol over 190 mg/dL and a family history of early heart disease it could be a genetic condition called familial hypercholesterolemia (FH). If you think you might have FH, talk to your doctor or connect with doctor who specializes in FH and other lipid disorders through our FH Specialist Map.

Does one’s gender affect their cholesterol?

Women may have a naturally higher HDL cholesterol than men. Cholesterol levels can rise during pregnancy and menopause as well. It is suggested not to get a cholesterol test during pregnancy because results can be inaccurate.

picture of healthy foods, nuts
Diet & Lifestyle Tips

Learn about healthy choices like the food we eat and physical activity.

Learn more
Diagnosing FH
Diagnosing FH

Extremely high LDL cholesterol could be a sign of FH.

Do I have FH?
Finding an FH Specialist
Finding an FH Specialist

We can help you find an FH specialist through a searchable database.

Find now

Page reviewed by Mary McGowan, MD
References

  1. Bucholz EM, Rodday AM, Kolor K, Khoury MJ, de Ferranti SD. Prevalence and Predictors of Cholesterol Screening, Awareness, and Statin Treatment Among US Adults With Familial Hypercholesterolemia or Other Forms of Severe Dyslipidemia (1999–2014). 2018;137:2218–2230.
  2. Grundy, S. M., Stone, N. J., Bailey, A. L., Beam, C., Birtcher, K. K., Blumenthal, R. S., . . . Yeboah, J. (2019). 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation, 139(25). doi:10.1161/cir.0000000000000625