Interpretation and Management of Normal Metabolic Panel with Borderline Lipid Abnormalities

Your laboratory values indicate excellent glycemic control and normal renal function, but reveal an atherogenic dyslipidemia pattern (borderline-high triglycerides with low HDL-cholesterol) that warrants aggressive lifestyle intervention and cardiovascular risk assessment before considering pharmacotherapy.

Laboratory Value Interpretation

Glycemic Parameters (Excellent Control)

Fasting glucose 5.35 mmol/L (96 mg/dL) and HbA1c 5.50% both fall within normal ranges, indicating no diabetes or prediabetes. 1
These values require no pharmacologic intervention but should be monitored annually if you have risk factors (family history, obesity, sedentary lifestyle). 1

Renal Function (Normal)

Creatinine 56.10 μmol/L (0.63 mg/dL) indicates normal kidney function with an estimated GFR well above 90 mL/min/1.73m². 2, 3
Uric acid 279 μmol/L (4.7 mg/dL) is within normal range and poses no immediate concern. 3, 4

Lipid Profile (Atherogenic Dyslipidemia Pattern)

Total Cholesterol: 3.15 mmol/L (122 mg/dL) – Low-Normal

This value is well below the 5.2 mmol/L (200 mg/dL) threshold and requires no intervention. 1

LDL-Cholesterol: 1.44 mmol/L (56 mg/dL) – Optimal

This is significantly below all guideline targets (<2.6 mmol/L or 100 mg/dL for most patients, <1.8 mmol/L or 70 mg/dL for high-risk patients). 1, 5
No LDL-lowering therapy is indicated at this level. 5

HDL-Cholesterol: 0.95 mmol/L (37 mg/dL) – Low (Major Risk Factor)

This value falls below the 1.03 mmol/L (40 mg/dL) threshold for men and 1.29 mmol/L (50 mg/dL) threshold for women, constituting an independent cardiovascular risk factor. 1
Low HDL-cholesterol is strongly associated with increased cardiovascular risk even when LDL-cholesterol is optimal. 5

Triglycerides: 1.68 mmol/L (149 mg/dL) – Borderline-High

This level falls just below the 1.7 mmol/L (150 mg/dL) threshold for "mild hypertriglyceridemia" but is approaching the range where intervention is recommended. 1, 6
Triglycerides ≥1.7 mmol/L (150 mg/dL) are classified as a cardiovascular risk-enhancing factor. 6, 5

Non-HDL Cholesterol: 2.20 mmol/L (85 mg/dL) – Optimal

Calculated as total cholesterol minus HDL-cholesterol (3.15 - 0.95 = 2.20 mmol/L).
This is well below the target of <3.4 mmol/L (130 mg/dL) for patients with elevated triglycerides. 6, 5

VLDL: 0.76 mmol/L (29 mg/dL) – Normal

This calculated value (triglycerides ÷ 2.2) is within normal range. 5

Clinical Significance: Atherogenic Dyslipidemia Pattern

Your lipid profile demonstrates the classic "atherogenic dyslipidemia" pattern characterized by:

Borderline-high triglycerides (1.68 mmol/L / 149 mg/dL)
Low HDL-cholesterol (0.95 mmol/L / 37 mg/dL)
Normal-to-low LDL-cholesterol (1.44 mmol/L / 56 mg/dL)

This pattern is strongly associated with insulin resistance, metabolic syndrome, and increased cardiovascular risk through elevated atherogenic VLDL remnant particles and small-dense LDL particles, even when calculated LDL-cholesterol appears optimal. 6, 5

Cardiovascular Risk Assessment Required

Before determining whether pharmacotherapy is needed, you must undergo formal cardiovascular risk stratification:

Calculate 10-Year ASCVD Risk

Use the Pooled Cohort Equations (available online) incorporating your age, sex, race, total cholesterol, HDL-cholesterol, systolic blood pressure, diabetes status, and smoking status. 6, 5
If 10-year ASCVD risk ≥7.5%, statin therapy is recommended regardless of LDL-cholesterol level. 6, 5
If 10-year ASCVD risk 5-7.5%, shared decision-making regarding statin initiation is appropriate, especially given your low HDL-cholesterol as a risk-enhancing factor. 6, 5

Screen for Metabolic Syndrome

You should be evaluated for metabolic syndrome, which is diagnosed when ≥3 of the following are present: 1

Waist circumference >102 cm (men) or >88 cm (women)
Triglycerides ≥1.7 mmol/L (150 mg/dL) – you are borderline
HDL-cholesterol <1.03 mmol/L (40 mg/dL) men or <1.29 mmol/L (50 mg/dL) women – you meet this criterion
Blood pressure ≥130/85 mmHg or on antihypertensive medication
Fasting glucose ≥5.6 mmol/L (100 mg/dL) or known diabetes – you do not meet this criterion

Assess for Secondary Causes

Before initiating any lipid-lowering therapy, the following must be evaluated: 6, 5

Thyroid function (TSH) – hypothyroidism commonly causes dyslipidemia
Fasting insulin or HOMA-IR – to assess for insulin resistance
Liver function tests (AST, ALT) – to exclude hepatic steatosis
Detailed alcohol history – even 1 oz daily can raise triglycerides by 5-10%
Medication review – thiazide diuretics, beta-blockers, oral estrogens, corticosteroids, antiretrovirals, and atypical antipsychotics can worsen lipid profiles

Management Algorithm

Step 1: Intensive Lifestyle Modifications (First-Line for All Patients)

Lifestyle interventions can lower triglycerides by 20-70% and raise HDL-cholesterol by 10-20%, potentially eliminating the need for pharmacotherapy. 6, 5

Weight Management (Most Effective Intervention)

Target 5-10% body weight reduction if overweight/obese, which yields approximately 20% triglyceride reduction and 5-10% HDL-cholesterol increase. 6, 5
In some individuals, weight loss alone can reduce triglycerides by 50-70%. 6

Dietary Modifications

Restrict added sugars to <6% of total daily calories (≈30 g on a 2000-kcal diet) because sugar intake directly stimulates hepatic triglyceride synthesis. 6, 5
Limit total dietary fat to 30-35% of calories for borderline-high triglycerides. 6, 5
Restrict saturated fat to <7% of total energy and replace with monounsaturated fats (olive oil, nuts, avocado) or polyunsaturated fats (fatty fish, flaxseed). 6, 5
Eliminate trans fatty acids completely – they lower HDL-cholesterol and raise triglycerides. 6, 5
Increase soluble fiber to >10 g/day from oats, beans, lentils, and vegetables. 6, 5
Consume ≥2 servings of fatty fish per week (salmon, trout, sardines, mackerel) to provide omega-3 fatty acids. 6, 5

Physical Activity

Engage in ≥150 minutes/week of moderate-intensity aerobic exercise (or 75 minutes/week vigorous activity), which reduces triglycerides by approximately 11% and raises HDL-cholesterol by 5-10%. 6, 5
Resistance training 2-3 times per week can further improve lipid profiles. 6

Alcohol Intake

Limit alcohol to ≤1-2 drinks per day for men, ≤1 drink per day for women. Even modest intake (≈1 oz daily) can raise triglycerides by 5-10%. 6, 5
Complete abstinence is required if triglycerides exceed 2.8 mmol/L (250 mg/dL). 6

Smoking Cessation

If you smoke, cessation is mandatory – smoking lowers HDL-cholesterol by 10-15% and significantly increases cardiovascular risk. 5

Step 2: Reassess Lipid Panel After 6-12 Weeks of Lifestyle Optimization

Obtain a fasting lipid panel 6-12 weeks after implementing intensive lifestyle changes to evaluate response. 6, 5
If triglycerides remain ≥1.7 mmol/L (150 mg/dL) and HDL-cholesterol remains low after documented adherence to lifestyle modifications, proceed to Step 3. 6, 5

Step 3: Pharmacotherapy Decision Based on Cardiovascular Risk

If 10-Year ASCVD Risk ≥7.5% OR Diabetes (Age 40-75) OR Established ASCVD:

Initiate moderate-to-high intensity statin therapy immediately (e.g., atorvastatin 10-20 mg or rosuvastatin 5-10 mg daily) alongside continued lifestyle optimization. 6, 5
Do NOT delay statin initiation while attempting lifestyle changes alone in high-risk patients – both should occur concurrently. 6, 5
Statins provide a dose-dependent 10-30% triglyceride reduction and proven cardiovascular mortality benefit through LDL-cholesterol lowering. 6, 5
Lipid targets while on statin therapy:
- LDL-cholesterol <2.6 mmol/L (100 mg/dL) – you already meet this
- Non-HDL-cholesterol <3.4 mmol/L (130 mg/dL) – you already meet this
- Triglycerides <2.3 mmol/L (200 mg/dL), ideally <1.7 mmol/L (150 mg/dL)
- HDL-cholesterol >1.03 mmol/L (40 mg/dL) men, >1.29 mmol/L (50 mg/dL) women 6, 5

If 10-Year ASCVD Risk 5-7.5%:

Engage in shared decision-making regarding statin initiation, considering your low HDL-cholesterol as a risk-enhancing factor. 6, 5
Factors favoring statin therapy include family history of premature ASCVD, chronic kidney disease, metabolic syndrome, or persistently elevated triglycerides ≥1.7 mmol/L (150 mg/dL). 6, 5

If 10-Year ASCVD Risk <5%:

Continue intensive lifestyle modification for at least 3 months before considering pharmacotherapy. 6, 5
Re-measure fasting lipid panel in 6-12 weeks after lifestyle implementation. 6, 5
Consider moderate-intensity statin only after shared decision-making if risk-enhancing factors are present and lipid abnormalities persist despite documented adherence to lifestyle changes. 6, 5

Step 4: Add-On Therapy If Triglycerides Remain ≥2.3 mmol/L (200 mg/dL) After 3 Months

This step is only relevant if your triglycerides rise above 2.3 mmol/L (200 mg/dL) despite statin therapy and lifestyle optimization:

Preferred Add-On: Icosapent Ethyl (Prescription EPA)

Icosapent ethyl 2 g twice daily (total 4 g/day) is indicated for patients with established cardiovascular disease OR diabetes plus ≥2 additional cardiovascular risk factors (e.g., hypertension, smoking, family history, age >50 years men/>60 years women, chronic kidney disease). 6, 5
The REDUCE-IT trial demonstrated a 25% relative risk reduction in major adverse cardiovascular events (NNT = 21 over 4.9 years). 6, 5
Icosapent ethyl is the only triglyceride-lowering agent FDA-approved for cardiovascular risk reduction. 6, 5
Monitor for atrial fibrillation (incidence 3.1% vs 2.1% with placebo). 6, 5

Alternative Add-On: Fenofibrate

Fenofibrate 54-160 mg daily may be considered if triglycerides remain >2.3 mmol/L (200 mg/dL) after 3 months of optimized lifestyle and statin therapy AND you do NOT meet icosapent ethyl criteria. 6, 5
Fenofibrate provides 30-50% triglyceride reduction and modest HDL-cholesterol increase. 6, 5
When combined with statins, use fenofibrate (NOT gemfibrozil) due to a markedly better safety profile; consider lower statin doses (atorvastatin ≤20 mg or rosuvastatin ≤10 mg) in patients >65 years or with renal impairment. 6, 5
Important caveat: The ACCORD trial demonstrated no cardiovascular event reduction when fenofibrate was added to simvastatin in diabetics, so fenofibrate's role is primarily triglyceride lowering without proven cardiovascular benefit. 6, 5

Monitoring Strategy

Reassess fasting lipid panel 6-12 weeks after implementing lifestyle modifications. 6, 5
If statin therapy is initiated, recheck lipids 4-8 weeks after starting or adjusting dose. 6, 5
Calculate non-HDL-cholesterol (total cholesterol minus HDL-cholesterol) and aim for <3.4 mmol/L (130 mg/dL) as a secondary target when triglycerides are elevated. 6, 5
If fenofibrate is added, obtain baseline and follow-up creatine kinase levels and monitor for muscle symptoms, especially when combined with statins. 6, 5
Monitor renal function at baseline, 3 months, and then every 6 months while on fenofibrate. 6, 5

Treatment Goals

Primary goal: Maintain triglycerides <1.7 mmol/L (150 mg/dL) to minimize cardiovascular risk. 6, 5
Secondary goal: Raise HDL-cholesterol to >1.03 mmol/L (40 mg/dL) for men or >1.29 mmol/L (50 mg/dL) for women. 6, 5
Tertiary goal: Maintain non-HDL-cholesterol <3.4 mmol/L (130 mg/dL). 6, 5
Quaternary goal: Keep LDL-cholesterol <2.6 mmol/L (100 mg/dL) for most patients, <1.8 mmol/L (70 mg/dL) for very high-risk patients. 5

Critical Pitfalls to Avoid

Do NOT ignore low HDL-cholesterol (<1.03 mmol/L or 40 mg/dL) – it remains an independent cardiovascular risk factor even when LDL-cholesterol is optimal. 5
Do NOT delay cardiovascular risk assessment – formal 10-year ASCVD risk calculation is essential to determine whether pharmacotherapy is indicated. 6, 5
Do NOT overlook secondary causes (hypothyroidism, insulin resistance, excess alcohol, offending medications) – correcting these can improve lipid profiles by 20-50% and may eliminate the need for additional agents. 6, 5
Do NOT rely on over-the-counter fish oil supplements for cardiovascular benefit – only prescription icosapent ethyl has proven outcome data. 6, 5
Do NOT start fenofibrate at your current triglyceride level (1.68 mmol/L or 149 mg/dL) – lifestyle modification is first-line, and fenofibrate is reserved for triglycerides ≥2.3 mmol/L (200 mg/dL) after lifestyle optimization. 6, 5
Do NOT use bile acid sequestrants if triglycerides exceed 2.3 mmol/L (200 mg/dL) – they can worsen hypertriglyceridemia. 5

Summary Recommendation

Immediate implementation of intensive lifestyle modifications (weight loss if overweight, dietary changes, aerobic exercise ≥150 min/week, alcohol moderation, smoking cessation if applicable). 6, 5
Formal cardiovascular risk assessment (10-year ASCVD risk calculation, metabolic syndrome screening, evaluation for secondary causes). 6, 5
Reassessment of fasting lipid panel in 6-12 weeks after documented adherence to lifestyle changes. 6, 5
Statin therapy initiation if 10-year ASCVD risk ≥7.5%, diabetes (age 40-75), or established ASCVD – do NOT delay pharmacotherapy in high-risk patients. 6, 5
Consideration of add-on therapy (icosapent ethyl or fenofibrate) only if triglycerides remain ≥2.3 mmol/L (200 mg/dL) after 3 months of optimized lifestyle and statin therapy. 6, 5

The cornerstone of your management is aggressive lifestyle intervention, which can lower triglycerides by 20-70% and raise HDL-cholesterol by 10-20%, potentially eliminating the need for pharmacotherapy if you are at low-to-moderate cardiovascular risk. 6, 5

How should I interpret and manage a patient with normal fasting glucose, normal HbA1c, normal renal function, normal uric acid, low‑normal total cholesterol, borderline‑high triglycerides, low HDL‑cholesterol and borderline LDL‑cholesterol?

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