Interpret the lab profile of an otherwise healthy adult who has mild hypercholesterolemia with elevated LDL cholesterol, normal HDL cholesterol, normal triglycerides, normoglycemia, normal renal function, normal hepatic function, a normal complete blood count, and euthyroid status, and advise on cardiovascular risk assessment and management.

Laboratory Interpretation: Mild Hypercholesterolemia with Favorable Metabolic Profile

This patient has borderline-elevated LDL cholesterol (128 mg/dL) and non-HDL cholesterol (150 mg/dL) but demonstrates excellent metabolic health otherwise—normal glucose metabolism (HbA1c 5.1%), protective HDL cholesterol (63 mg/dL), normal triglycerides (110 mg/dL), normal thyroid function, and preserved renal function (eGFR 104 mL/min/1.73m²).

Lipid Profile Analysis

Primary Findings

• Total cholesterol 213 mg/dL (mildly elevated above the <200 mg/dL threshold) 1
• LDL cholesterol 128 mg/dL (above optimal <100 mg/dL but below high-risk thresholds) 1
• Non-HDL cholesterol 150 mg/dL (elevated above <130 mg/dL target) 1
• HDL cholesterol 63 mg/dL (protective; well above the 40 mg/dL minimum for men or 50 mg/dL for women) 1
• Triglycerides 110 mg/dL (normal, <150 mg/dL) 1

Favorable Risk Ratios

• Total cholesterol/HDL ratio 3.4 (excellent; <5.0 is desirable, and this patient's ratio confers below-average cardiovascular risk) 2, 3
• LDL/HDL ratio 2.0 (below-average risk; <2.28 indicates lower coronary heart disease risk) 2, 3

The total cholesterol/HDL ratio is a superior predictor of coronary heart disease compared to LDL cholesterol alone and provides independent risk-discriminating ability 2. This patient's ratio of 3.4 places them in a favorable risk category despite the mildly elevated absolute LDL value 2, 3.

Cardiovascular Risk Stratification

Risk Factor Assessment

To determine treatment intensity, assess for the following 1:

• Age: Men >55 years or women >65 years 1
• Smoking status (current or recent) 1
• Hypertension (BP ≥140/90 mmHg or on antihypertensive medication) 1
• Family history of premature cardiovascular disease (men <55 years, women <65 years) 1
• Diabetes mellitus (this patient's HbA1c 5.1% rules out diabetes) 1
• Chronic kidney disease (eGFR <60 mL/min/1.73m²; this patient's eGFR 104 is normal) 1

LDL Treatment Targets by Risk Category

The European guidelines stratify LDL goals based on total cardiovascular risk 1:

• Low/moderate risk (no additional risk factors): LDL <115 mg/dL (3.0 mmol/L) 1
• High risk (≥2 risk factors or subclinical atherosclerosis): LDL <70 mg/dL (1.8 mmol/L) 1
• Very high risk (established cardiovascular disease or diabetes with organ damage): LDL <55 mg/dL (1.4 mmol/L) 1

This patient's LDL of 128 mg/dL exceeds the low/moderate-risk target of <100–115 mg/dL but may not require pharmacotherapy if no additional risk factors are present 1.

Metabolic & Renal Health

Glucose Metabolism

• Fasting glucose 87 mg/dL (optimal; 65–99 mg/dL) 1
• HbA1c 5.1% (excellent; <5.7% is non-diabetic) 1
• Mean plasma glucose 104 mg/dL (derived from HbA1c; normal) 1

This patient has no evidence of prediabetes or diabetes, which are major cardiovascular risk equivalents 1.

Renal Function

• Creatinine 0.93 mg/dL (normal) 1
• eGFR 104 mL/min/1.73m² (normal; ≥60 is the threshold for preserved function) 1
• BUN 14 mg/dL and BUN/creatinine ratio 15 (both normal) 1

Normal renal function excludes chronic kidney disease as a cardiovascular risk factor 1. Higher HDL cholesterol is causally associated with better kidney function 4.

Hepatic Function

• AST 19 U/L, ALT 26 U/L, alkaline phosphatase 80 U/L, total bilirubin 0.4 mg/dL (all normal) 1
• Albumin 4.6 g/dL, total protein 7.5 g/dL (normal synthetic function) 1

No evidence of hepatic steatosis or dysfunction, which can be associated with metabolic syndrome 1, 5.

Thyroid Function

• TSH 1.13 mIU/L (normal; 0.40–4.50 range) 1

Normal thyroid function excludes hypothyroidism as a secondary cause of dyslipidemia 1, 6, 5. Low-normal thyroid function (higher TSH within the reference range) has been associated with modest increases in total cholesterol, LDL cholesterol, and triglycerides, but this patient's TSH is mid-range 5.

Hematologic Profile

• Hemoglobin 16.7 g/dL, hematocrit 49.0% (normal for men; slightly high-normal, consistent with adequate hydration or mild polycythemia) 1
• White blood cell count 8.9 × 10³/µL, platelet count 316 × 10³/µL (normal) 1
• MCV 91.2 fL, MCH 31.1 pg, MCHC 34.1 g/dL (normocytic, normochromic red cells) 1
• Differential: neutrophils, lymphocytes, monocytes, eosinophils, basophils all within normal ranges 1

No evidence of anemia, infection, or hematologic disorder.

Management Recommendations

First-Line: Intensive Therapeutic Lifestyle Changes

All patients with borderline-elevated LDL cholesterol should receive counseling on cardiovascular risk factors and lifestyle modifications 1:

• Dietary fat modification 1, 7:

  • Limit saturated fat to <7% of total calories 7
  • Dietary cholesterol <200 mg/day 7
  • Eliminate trans fats completely 7
  • Replace saturated fats with monounsaturated fats (olive oil, avocado, nuts) rather than refined carbohydrates 7

• Increase soluble fiber to 10–25 g/day from oats, legumes, barley, psyllium 1, 7

• Add plant sterols/stanols 2 g/day to diet 1, 7

• Physical activity: ≥150 minutes/week of moderate-intensity aerobic exercise (brisk walking, cycling, swimming) 1, 7

• Weight management: If overweight, achieve 5–10% body weight reduction 7

• Limit alcohol to ≤1 drink/day for women, ≤2 drinks/day for men 1

• Smoking cessation if applicable 1

Monitoring Strategy

• Repeat fasting lipid panel in 3–6 months after initiating lifestyle changes 1, 7
• Use non-fasting lipids for routine monitoring once treatment is stable, but use fasting LDL cholesterol when making treatment decisions, especially if triglycerides are elevated 1
• Annual lipid panel once targets are achieved 7

Pharmacotherapy Thresholds

Statin therapy is NOT immediately indicated for this patient if they are at low/moderate cardiovascular risk (i.e., <2 additional risk factors beyond the mild LDL elevation) 1. The decision to initiate a statin depends on:

1. 10-year ASCVD risk calculation using the Pooled Cohort Equation (requires age, sex, race, blood pressure, smoking status, and diabetes status) 1
2. Presence of ≥2 major risk factors (age, smoking, hypertension, family history, low HDL <40 mg/dL) 1

If 10-year ASCVD risk is ≥10% OR if ≥2 risk factors are present, consider initiating a moderate-intensity statin (atorvastatin 10–20 mg or rosuvastatin 5–10 mg daily) with a target LDL <100 mg/dL 1, 7, 8.

If 10-year ASCVD risk is <10% AND <2 risk factors, continue intensive lifestyle modification for 6–12 months before reassessing 1.

Secondary Treatment Goals

• Non-HDL cholesterol target <130 mg/dL (currently 150 mg/dL) 1, 7
• Apolipoprotein B may be considered as an alternative target, particularly if triglycerides are elevated, though this patient's normal triglycerides make this less relevant 1

Common Pitfalls to Avoid

• Do not initiate statin therapy based solely on LDL cholesterol without assessing total cardiovascular risk 1, 2. This patient's favorable HDL cholesterol and cholesterol ratios indicate lower risk than the absolute LDL value suggests 2, 3.

• Do not ignore the protective effect of high HDL cholesterol (63 mg/dL). Higher HDL is causally associated with better cardiovascular and renal outcomes 4.

• Do not replace saturated fat with high-glycemic carbohydrates during dietary modification, as this can worsen triglycerides; monounsaturated fat substitution is preferred 7.

• Do not overlook secondary causes of dyslipidemia (hypothyroidism, chronic kidney disease, diabetes, liver disease, nephrotic syndrome)—all have been excluded in this patient 1, 6, 5.

• Do not defer lifestyle intervention even if pharmacotherapy is not yet indicated; dietary changes and exercise can reduce LDL cholesterol by 10–20% 1, 7.