Management of Low HDL-C with Elevated Triglycerides in a 60-Year-Old Black Female
This patient requires immediate initiation of moderate-intensity statin therapy combined with aggressive lifestyle modification, despite the low total cholesterol, because her markedly low HDL-C (27 mg/dL) and elevated triglycerides (194 mg/dL) place her at substantially increased cardiovascular risk.
Critical Lipid Abnormalities Identified
HDL-C of 27 mg/dL is severely low, falling well below the protective threshold of ≥50 mg/dL for women and representing a major independent cardiovascular risk factor 1.
Triglycerides of 194 mg/dL are elevated (normal <150 mg/dL), requiring both lifestyle intervention and consideration of the non-HDL-C target 1.
Non-HDL cholesterol of 72 mg/dL is already below the target of <130 mg/dL for patients with triglycerides 200–499 mg/dL, which is favorable 1.
Total cholesterol of 99 mg/dL is unusually low but does not negate cardiovascular risk when HDL-C is severely depressed 2.
Race-Specific Considerations for Black Women
Low HDL-C may have different prognostic implications in Black adults compared to White adults; recent evidence suggests that low HDL-C (<40 mg/dL in men, <50 mg/dL in women) was associated with increased coronary heart disease risk in White adults (HR 1.22) but not in Black adults (HR 0.94, P interaction = 0.08) 3.
However, an HDL-C of 27 mg/dL represents an extreme value that warrants intervention regardless of race, as this level is associated with potential secondary causes and metabolic abnormalities 4.
The lipid pattern of low HDL-C with normal-to-borderline triglycerides is the most common dyslipidemia in West Africans and African Americans with metabolic syndrome, occurring in >60% of cases 5.
Immediate Therapeutic Interventions
Pharmacologic Therapy
Initiate a moderate-intensity statin immediately (e.g., atorvastatin 10–20 mg daily or rosuvastatin 5–10 mg daily) with the goal of raising HDL-C and lowering LDL-C to <100 mg/dL, even though calculated LDL-C may already be low 1, 6.
Statins provide 3–6% HDL-C elevation in addition to LDL-C reduction and have proven cardiovascular benefit in patients with low HDL-C when combined with LDL-lowering 1.
After maximizing statin therapy and lifestyle changes, if HDL-C remains <40 mg/dL and triglycerides remain elevated, consider adding fenofibrate 54–160 mg daily (start at 54 mg given potential renal considerations in a 60-year-old) 1, 7.
Fenofibrate is FDA-approved as adjunctive therapy to diet for mixed dyslipidemia, specifically to increase HDL-C and reduce triglycerides 7.
Combination statin plus fibrate increases myopathy risk; keep statin doses relatively low (e.g., atorvastatin 10–20 mg) if combining with fenofibrate 1.
Comprehensive Lifestyle Modifications
Dietary Interventions
Reduce saturated fat to <7% of total daily calories by eliminating cheese, whole milk, fatty red meat, butter, and tropical oils 1, 6.
Eliminate trans-fatty acids (aim for <1% of total energy) by avoiding partially hydrogenated oils and commercial baked goods 1, 6.
Replace saturated fats with monounsaturated fats (olive oil, canola oil, avocados) and omega-3 fatty acids (fatty fish twice weekly or 1 g/day fish oil supplement) 1, 6.
Reduce simple carbohydrates and sugar-sweetened beverages to lower triglycerides by 20–50% 6.
Consume 10–25 g/day of soluble fiber from oats, beans, lentils, vegetables, and whole grains 1, 6.
Add 2 g/day of plant stanols/sterols via fortified products 1, 6.
Physical Activity
Perform moderate-intensity aerobic exercise ≥30 minutes on most days (brisk walking, jogging, cycling); substantial exercise volume (1500–2200 kcal/week) is required to raise HDL-C by 3–6 mg/dL 6, 8.
Include resistance training 2 days per week: 8–10 exercises, 1–2 sets of 10–15 repetitions at moderate intensity 6.
Weight Management & Other Factors
If BMI ≥25 kg/m², target 10% body-weight reduction in the first year; each kilogram lost raises HDL-C by approximately 0.4 mg/dL 6.
Smoking cessation is mandatory if applicable, as smoking independently lowers HDL-C 6, 8.
Limit alcohol to ≤1 drink per day for women; moderate consumption may raise HDL-C, but excess intake elevates triglycerides 6, 8.
Evaluation for Secondary Causes
Measure thyroid-stimulating hormone (TSH) to exclude hypothyroidism, which can cause low HDL-C and elevated triglycerides 9.
Obtain fasting glucose or HbA1c to screen for diabetes or prediabetes, which are common contributors to this lipid pattern 9.
Review medications for agents that lower HDL-C (certain beta-blockers, thiazide diuretics, progestational agents, androgens) 1, 8.
Assess for chronic kidney disease with estimated GFR and urinalysis 9.
Consider liver function tests to exclude hepatic causes of dyslipidemia 9.
Monitoring Protocol
Obtain baseline hepatic transaminases (ALT/AST) and creatine kinase before starting statin therapy 6.
Recheck fasting lipid panel 4–6 weeks after initiating statin to assess HDL-C response and confirm triglyceride reduction 6, 9.
If adding fenofibrate, start at 54 mg daily in a 60-year-old and increase only after evaluating renal function and lipid response at this dose 7.
Once lipid goals are achieved, perform annual fasting lipid assessments 6, 9.
Screen for muscle symptoms at each visit; obtain creatine kinase only if musculoskeletal complaints develop 6.
Treatment Goals
Primary goal: Raise HDL-C toward ≥50 mg/dL for women through combined pharmacologic and lifestyle interventions 1, 10.
Secondary goal: Reduce triglycerides to <150 mg/dL 1.
Tertiary goal: Maintain non-HDL-C <130 mg/dL, which is already achieved 1.
Critical Pitfalls to Avoid
Do not dismiss cardiovascular risk based solely on low total cholesterol (99 mg/dL); severely low HDL-C (27 mg/dL) is an independent and potent risk factor 2, 4.
Do not delay statin therapy for a 12-week lifestyle-only trial when HDL-C is this severely depressed; initiate pharmacotherapy and lifestyle changes simultaneously 10, 9.
Do not rely on HDL-C/LDL-C ratios or total cholesterol/HDL-C ratios for treatment decisions; these are obsolete measures 8, 2.
Do not prescribe fibrate monotherapy without a statin in this patient; statins provide broader cardiovascular benefit and should be the foundation of therapy 1, 7.
Do not overlook the race-specific lipid pattern; low HDL-C with borderline triglycerides is the most common dyslipidemia in Black women with metabolic syndrome and requires aggressive management 5.
Do not start fenofibrate at 160 mg daily in a 60-year-old; initiate at 54 mg and titrate based on renal function and lipid response 7.