Given a patient with HDL‑C (high‑density lipoprotein cholesterol) 27 mg/dL, total cholesterol 170 mg/dL, LDL‑C (low‑density lipoprotein cholesterol) 116 mg/dL, triglycerides 152 mg/dL, cholesterol/HDL ratio 6.3, and non‑HDL‑C (non‑high‑density lipoprotein cholesterol) 143 mg/dL, what is the most likely diagnosis?

Atherogenic Dyslipidemia (Metabolic Dyslipidemia)

This patient has atherogenic dyslipidemia, characterized by the classic lipid triad: elevated triglycerides (152 mg/dL), markedly low HDL-C (27 mg/dL), and a significantly elevated total cholesterol/HDL ratio (6.3). 1, 2

Diagnostic Features Present

The lipid profile demonstrates all three cardinal features of atherogenic dyslipidemia:

• Severely low HDL-C at 27 mg/dL - well below the threshold of <40 mg/dL that defines increased cardiovascular risk 1, 3
• Elevated triglycerides at 152 mg/dL - above the 150 mg/dL threshold that marks increased cardiovascular risk 3, 4
• Markedly elevated cholesterol/HDL ratio of 6.3 - this ratio is currently the most powerful single predictor of risk in dyslipidemic patients 2
• Elevated non-HDL-C at 143 mg/dL - indicating increased atherogenic particle burden 1, 5

Pathophysiology and Clinical Significance

This lipid pattern reflects underlying metabolic dysfunction:

• The combination represents the "atherogenic lipid triad" consisting of increased VLDL remnants (manifested as elevated triglycerides), increased small dense LDL particles, and reduced HDL-C levels 1, 4
• This pattern is strongly associated with insulin resistance, metabolic syndrome, type 2 diabetes, obesity, and physical inactivity 1, 6, 7
• The dyslipidemia results from dysregulation of hepatic fat metabolism with overproduction of VLDL particles due to increased free fatty acid release from adipose tissue 1, 7

Cardiovascular Risk Assessment

The cardiovascular risk is substantially elevated:

• Atherogenic dyslipidemia is an independent predictor of cardiovascular risk, stronger than isolated high triglycerides or low HDL cholesterol alone 1
• The total cholesterol/HDL ratio of 6.3 indicates significantly increased risk - optimal ratios are much lower 2, 6
• Even though LDL-C appears borderline at 116 mg/dL, the patient likely has predominantly small, dense LDL particles which are more prone to oxidation and more atherogenic 1, 4

Common Pitfalls to Avoid

• Do not be falsely reassured by the "borderline" LDL-C of 116 mg/dL - the LDL particle number is likely elevated despite seemingly acceptable LDL-C levels, and the particles are predominantly small and dense 6, 4
• Do not rely solely on Framingham risk score or LDL measurements - atherogenic dyslipidemia is poorly reflected in these traditional metrics 6
• Recognize that this pattern indicates high cardiovascular risk regardless of other risk factors - the severely low HDL-C alone (27 mg/dL) is a major red flag 1, 3

Associated Conditions to Evaluate

Investigate for underlying metabolic disorders:

• Screen for type 2 diabetes or prediabetes with fasting glucose and HbA1c 1, 6, 7
• Assess for metabolic syndrome - check for central obesity, hypertension, and glucose intolerance 1, 7
• Evaluate for insulin resistance - this is the hallmark metabolic abnormality driving this lipid pattern 1, 4
• Consider secondary causes including hypothyroidism, nephrotic syndrome, and medications that may worsen the lipid profile 1