Are These Cholesterol Levels Too Low?
Your HDL of 35 mg/dL is concerning and warrants intervention, while your LDL of 33 mg/dL is acceptable and safe on statin therapy.
Understanding Your HDL Level
Your HDL cholesterol of 35 mg/dL falls below the recommended threshold and represents a cardiovascular risk factor that needs addressing:
HDL levels below 40 mg/dL for men are considered a risk-enhancing factor for cardiovascular disease, even when LDL is well-controlled 1.
The 2004 NCEP ATP III guidelines explicitly identify low HDL-C (<40 mg/dL) as part of the metabolic syndrome criteria and a target for intervention 1.
Low HDL is associated with increased cardiovascular risk independent of LDL levels, and addressing this becomes important even when LDL goals are achieved 1.
Understanding Your LDL Level
Your LDL of 33 mg/dL is not only safe but potentially beneficial:
There is no established lower threshold for LDL cholesterol below which harm occurs when achieved through statin therapy 1.
The 2004 ATP III update introduced an optional LDL goal of <70 mg/dL for very high-risk patients, and clinical trials have shown safety with LDL levels as low as 26 mg/dL without adverse effects 2.
Recent clinical trials documented no safety signals with on-treatment LDL levels ranging from 26-70 mg/dL over 2 years, with no increase in adverse events at progressively lower levels 1, 2.
The log-linear relationship between LDL and cardiovascular risk suggests continued benefit even at very low levels, with no evidence of a threshold below which benefit stops 1.
What You Should Do About Your HDL
The priority is raising your HDL through lifestyle modifications first, then considering pharmacologic options if needed:
Immediate Lifestyle Interventions:
Engage in at least 150 minutes per week of moderate-intensity aerobic activity, which can increase HDL by 5-10% 3.
Achieve a 5-10% weight loss if overweight, as this improves HDL levels significantly 3.
Completely eliminate trans fats and restrict saturated fats to <7% of total calories, replacing with monounsaturated or polyunsaturated fats 3.
If you consume alcohol and have no contraindications, moderate intake (1-2 drinks daily for men) may modestly increase HDL, though this must be balanced against other health considerations 3.
Pharmacologic Considerations:
If HDL remains <40 mg/dL after 3 months of lifestyle optimization, discuss adding niacin or a fibrate with your physician 1.
Niacin can increase HDL by 15-35% but requires monitoring for side effects including flushing and glucose intolerance 1.
Fibrates (particularly fenofibrate) can increase HDL by 10-20% and have a favorable safety profile when combined with statins 3.
Important Caveats About Your Statin Therapy
Do not reduce or stop your statin based on the low LDL level:
Your statin is providing proven cardiovascular benefit beyond just LDL lowering, including plaque stabilization and anti-inflammatory effects 1.
The 2013 ACC/AHA guidelines moved away from rigid LDL targets toward maintaining evidence-based statin therapy in appropriate patients 1.
If you're on a high-dose statin (atorvastatin 40-80 mg or rosuvastatin 20-40 mg), this is appropriate for secondary prevention or high-risk primary prevention 1.
Monitor for Statin-Related HDL Effects:
Atorvastatin specifically has been reported to show a negative dose-response relationship with HDL, meaning higher doses may actually lower HDL in some patients 4, 5.
If you're on high-dose atorvastatin, discuss with your physician whether switching to a different statin (like simvastatin or rosuvastatin) might improve your HDL response while maintaining LDL control 4.
What to Discuss With Your Doctor
Bring these specific points to your next appointment:
Request a complete lipid panel including triglycerides and non-HDL cholesterol to better assess your overall cardiovascular risk 1.
Ask whether your current statin dose and type is optimal given your low HDL response 4.
Discuss whether you meet criteria for adding HDL-raising therapy based on your overall cardiovascular risk profile 1.
Ensure you're being monitored for other cardiovascular risk factors including blood pressure, glucose, and inflammatory markers 1.
The bottom line: Your LDL is fine and safe at 33 mg/dL on statin therapy, but your HDL of 35 mg/dL needs attention through lifestyle changes and potentially medication adjustment.