What is the desirable Low-Density Lipoprotein (LDL) to High-Density Lipoprotein (HDL) ratio for men?

LDL to HDL Ratio for Men

There is no established "desirable" LDL to HDL ratio target for men in current clinical guidelines—instead, focus on absolute LDL cholesterol targets based on cardiovascular risk category and recognize that HDL <40 mg/dL indicates increased risk, though HDL itself is not a treatment target. 1

Why Ratios Are Not Primary Treatment Targets

Current evidence-based guidelines from the American College of Cardiology, American Heart Association, and European Society of Cardiology have moved away from using LDL/HDL ratios as primary treatment targets. The therapeutic focus should be on achieving absolute LDL cholesterol goals based on your total cardiovascular risk category. 1

Absolute Thresholds That Matter

For HDL cholesterol in men:

• HDL <40 mg/dL (1.04 mmol/L) indicates increased cardiovascular risk and is one criterion for metabolic syndrome 1
• This threshold is used for risk stratification, not as a treatment target 1

For LDL cholesterol treatment goals:

• Very high-risk patients (documented CVD, diabetes with target organ damage): LDL <70 mg/dL (1.8 mmol/L) 1
• High-risk patients: LDL <100 mg/dL (2.6 mmol/L) 1
• Moderate-risk patients: individualized based on SCORE or Framingham risk assessment 1

Alternative Ratios With More Clinical Utility

While LDL/HDL ratio is not emphasized, other ratios provide better risk stratification:

Total Cholesterol to HDL Ratio

• The TC/HDL-C ratio may be superior to LDL/HDL ratio, particularly in overweight hyperinsulinemic patients with high triglycerides 2
• This ratio captures more metabolic abnormalities associated with insulin resistance syndrome than LDL/HDL ratio alone 2

Triglyceride to HDL Ratio

• A TG/HDL ratio >0.9 (using mmol/L) or >2.0 (using mg/dL) suggests the presence of small, dense LDL particles, which are more atherogenic 3
• This ratio is particularly useful for identifying patients with atherogenic dyslipidemia 4, 3
• The combination of elevated triglycerides and low HDL is extremely common in high-risk patients with type 2 diabetes, abdominal obesity, and insulin resistance 4

Clinical Approach to Low HDL in Men

When you encounter a man with HDL <40 mg/dL:

1. Assess for secondary causes: hyperglycemia, diabetes, hypertriglyceridemia, very low-fat diets (<15% energy as fat), excess body weight, and smoking 1

2. Implement lifestyle interventions (these are the primary interventions for low HDL):

   • Weight loss if overweight or obese 1
   • Increased physical activity 1, 5
   • Smoking cessation 5
   • Moderate alcohol consumption (if appropriate) 1

3. Prioritize LDL lowering with statins as first-line pharmacotherapy, not HDL-raising agents 1

   • Statins remain the cornerstone even when low HDL is present 5
   • Every 30 mg/dL reduction in LDL produces proportional cardiovascular risk reduction 5

4. Consider fibrates only when triglycerides are markedly elevated (≥150 mg/dL) after optimizing glycemic control and lifestyle 1, 4

   • Fibrates can raise HDL significantly without affecting glycemic control 1
   • However, raising HDL pharmacologically has not been proven to reduce cardiovascular events 1, 6

Important Clinical Caveats

Do not use HDL as a therapeutic target. Multiple trials attempting to raise HDL pharmacologically (niacin, CETP inhibitors) have failed to demonstrate cardiovascular benefit, despite successfully raising HDL levels 1, 6. This suggests that low HDL is a risk marker rather than a causal factor 4.

The relationship between lipid ratios and risk varies by ethnicity. Black patients with metabolic syndrome may not exhibit high triglycerides as commonly as other ethnic groups, affecting the interpretation of TG/HDL ratios 4.

Primary low HDL cholesterol (HDL <40 mg/dL in men with triglycerides <100 mg/dL and LDL <100 mg/dL) still confers 2.25-fold increased risk of coronary heart disease compared to optimal lipid profiles 7. These patients warrant aggressive lifestyle modification even though their LDL is already low 7.