How many times have I said “LDL – Bad, HDL – Good” to my patients? Thousands of times over the past years of practice, I have described the differing effects of LDL and HDL on cardiovascular health, yet researchers want to overturn this dogma, this law of medicine. Once again, little in medicine stands so sacred that it cannot be nullified with a newer study. Evidence based medicine proclaims itself as the gold standard yet undermines itself month after month with new studies that overturn old ones. In this case, researchers assert that HDL over 60 increases heart attack risk in patients who already have heart disease.
While this sounds like grand and earth shattering, the Institute for Functional Medicine discussed this in a conference years ago. As that lecturer explained the mechanisms of cholesterol movement throughout the body and its contributions to heart disease, he declared that cholesterol serves in our military, our immune system that is. He described the function of both LDL and HDL in cleaning up post immune defense for infections and toxin removal. This led him to also argue that excessively high HDL is likely a marker for increased immune reactivity and inflammation. Knowing that inflammation plays a critical role in heart disease progression, he suggested that the good functional MD should be alert when HDL is over 80.
At the end of a longer discussion about heart health, I have often addressed this with my uncommon patient who does have higher HDL. We spend some time looking at their advanced cardiac cholesterol panel in which we have measured their LDL particle number and assessed the relative sizes of their LDLs. These two factors highlight patients who are at higher risk for heart disease even if their LDL is “good”. I then consider the size of the HDL, hoping for their sake that the HDL “dump truck” are larger meaning they do a better job at cleaning up after their LDL cousins. Beyond that we look at HSCRP (high sensitivity C Reactive Protein) to assess whether they have smoldering inflammation which puts them at higher risk. A look at their Lp(a) risk factor wraps up the discussion unless we dig further with Lp PLA-2 or MPO.
At this point for my uncommon patient with HDL over 80, I would stop and look around their body systems to see if some toxin or infection might be triggering an elevated HDL. If we found something by history or testing, we would treat accordingly. We might find a lingering viral infection or a smoldering mycoplasma infection. Occasionally we would find some mercury that required detoxing. If nothing showed up clearly, I would keep my eyes open as I followed the patient over time.
With this new report regarding a 50% increase in heart attack or cardiovascular death for patients with an HDL over 60, I am encouraged that the world of functional medicine truly walks a step ahead of conventional medicine. With functional medicine in my tool belt, I can feel confident that Sanctuary can help our patients live healthier more abundant lives.
European Society of Cardiology. “Too much of a good thing? Very high levels of ‘good’ cholesterol may be harmful.” ScienceDaily. ScienceDaily, 25 August 2018. <www.sciencedaily.com/releases/2018/08/180825081724.htm>