Cholesterol and Risk of Heart Attack

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Q. Glen, I often read that a person's cholesterol should be under 200, yet have also read (on several occasions) that most people that have heart attacks have cholesterol in the 180 to 200 range. Can you help me to understand this? Thank you!


A. It is confusing, but I'll try to clarify. The problem is that what's considered "normal" or average cholesterol in our society is not biologically normal for our arteries. So when I hear people say heart attacks occur when cholesterol is normal (e.g., 180 to 200 mg/dL), I cringe.

Total cholesterol is made up of good and bad cholesterol. You can have a total cholesterol level of less than 200 mg/dL but that may be because your good (HDL) cholesterol is low, which may put you at risk of heart disease. That's why I like to look at all the numbers, the good (HDL) cholesterol, the bad (LDL) cholesterol, and the "ugly" (triglycerides) in addition to the total cholesterol. The goal for total cholesterol is less than 200 mg/dL, the goal for bad (LDL) cholesterol is less than 100 mg/dL, the goal for good (HDL) cholesterol is 40 mg/dL or higher in men and 50 mg/dL or higher in women, and the goal for triglycerides is less than 150 mg/dL.

The higher your cholesterol levels (total and LDL), the greater the likelihood of heart disease. The Multiple Risk Factor Intervention Trial (a national heart-disease prevention study conducted from 1973 to 1982) showed that the likelihood of heart attack in people with cholesterol levels in the highest 20 percent was three times that of people whose levels were in the lowest 20 percent. Another well-known survey, the Framingham study, also illustrated the link between high cholesterol levels and heart disease.

In both studies, however, a significant number of heart attacks still occurred in people with low or "normal" cholesterol values. In the Framingham study, four of five people fell into a large middle range of cholesterol levels, whether or not they developed heart disease. Those with extremely low total cholesterol (less than 50 mg/dL) had low (though not zero) risk for heart attack; those with extremely high cholesterol (over 300 mg/dL) had a threefold higher risk for heart attack. But the great majority of people fell in between these extremes, and the greatest number of heart attacks developed in people with cholesterol levels in this middle range. Why? Because people with low or middle-range cholesterol values vastly outnumber those with high cholesterol levels. As a result, there are at least as many heart attack victims with low and intermediate cholesterol levels as there are those with high cholesterol.

The bottom line: The higher the cholesterol, the higher the statistical risk of heart attack, yet a surprising number of heart attacks still occur in people who have "normal" cholesterol levels because "normal" in our society is too high. I hope that helps.

Any personal health questions or problems mental or physical or before starting any diet or exercise program. Please consult your physician !

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Yours in good health

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