Current clinical guidelines set relatively strict targets for controlling LDL cholesterol, which means that many individuals, even when their LDL levels are already near the lower range, are still advised to take cholesterol-lowering medications. At the same time, the protective role of HDL cholesterol is often not given sufficient attention.
Evidence from research shows that relying solely on LDL as the basis for risk assessment may not be comprehensive. Some independent researchers argue that using total cholesterol to HDL ratios, LDL to HDL ratios, or non-HDL cholesterol as markers can more accurately reflect cardiovascular risk and may provide greater clinical value than focusing on LDL alone.
It is worth noting that the European Society of Cardiology and a number of European cardiologists have already recommended incorporating non-HDL cholesterol and ApoB into clinical practice as risk assessment and treatment targets, to make up for the shortcomings of relying only on LDL. In the United States, however, guidelines still emphasize LDL reduction as the primary treatment goal, and the use of ratios or ApoB in practice is far less common. This highlights a clear difference between European and American approaches to cardiovascular risk assessment.
The main reason the U.S. continues to emphasize LDL is that nearly all large-scale randomized controlled trials have used LDL-C reduction as the primary endpoint and treatment target, thereby reinforcing LDL’s role within the framework of evidence-based medicine. However, with the wider availability of ApoB testing and growing research showing its superiority in predicting cardiovascular risk, it is likely that the U.S. will eventually incorporate ApoB or non-HDL cholesterol more broadly into clinical practice.
On this point, there is a clear difference in attitude between American and European doctors:
| U.S. Approach | European Approach |
---|
Primary focus | LDL-C (“bad cholesterol”) | Non-HDL cholesterol, ApoB, ratios (e.g., total cholesterol/HDL) |
Basis for prescribing medication | Whether LDL meets the target | A more comprehensive risk assessment, not just LDL |
Guideline stance | Still centered on LDL, because most clinical trials use LDL as the benchmark | Increasingly emphasizes ApoB and non-HDL, viewing them as more accurate |
Attention to HDL (“good cholesterol”) | Relatively little emphasis | More consideration of HDL’s protective role |
Future trend | May gradually introduce ApoB and non-HDL measures | Already promoting these markers in guidelines |
The U.S. approach is relatively narrow, focusing mainly on LDL to decide whether to prescribe medication, while Europe takes a more comprehensive view, incorporating HDL, non-HDL, and ApoB into the assessment. As ApoB testing becomes more widely available, the U.S. may eventually follow suit.
Peter went for a medical checkup, and his report showed that his LDL (commonly known as “bad cholesterol”) was slightly elevated. The doctor looked at the report and immediately suggested cholesterol-lowering medication. Strangely, however, Peter’s HDL (“good cholesterol”) level was quite good, yet nobody mentioned it. Peter wondered: is heart health really judged only by LDL?
In reality, the answer is not that simple. In the United States, doctors often set very low targets for LDL. Even if your LDL is already close to the normal range, you may still be advised to take medication. At the same time, the protective role of HDL is frequently overlooked.
Some studies have found that looking only at LDL does not fully reflect the risk of heart disease. A more meaningful approach is to consider HDL at the same time, or to use more comprehensive markers, such as the “total cholesterol-to-HDL ratio,” the “LDL-to-HDL ratio,” or “non-HDL cholesterol.”