Ethnicity and coronary artery disease: the role of high-density lipoprotein – a change in paradigm

Abstract

Cardiovascular disease (CVD) is the number one killer of men and women across ethnic groups in the USA. Health disparities in CVD, especially coronary artery disease (CAD), are well documented in the diverse American population. Despite efforts taken toward reducing cardiovascular health disparities, there are still gaps in its diagnosis and management. Current risk assessment guidelines consider high high-density lipoprotein (HDL) levels a protective factor against CAD, although its significance across races remains poorly understood. Recent clinical trials focused on increasing HDL levels have been disappointing. In this article, the authors have explored the role of HDL in CAD, have analyzed its significance across gender and ethnic groups and have challenged the broad application of widely used HDL level cutoffs in CAD risk assessment tools across these vulnerable groups. The current evidence suggests a paradigm change from HDL quantity to quality and function in future CVD risk research. This may better explain why some ethnic minority groups with a seemingly more benign lipid profile experience a higher CAD burden.

Keywords:

• coronary artery disease
• ethnicity
• health disparities
• high-density lipoprotein cholesterol

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• For a long time, high-density lipoprotein (HDL) levels have been considered atheroprotective and have played an important role in coronary artery disease (CAD) risk prediction. However, HDL levels differ among gender and racial and ethnic groups.

• Blacks, postmenopausal women and Native Americans have higher HDL levels but appear to receive minimal protection from it. Moreover, therapies that target HDL levels have failed to improve cardiovascular outcomes.

• The concept of HDL function has emerged as a promising marker and recent studies have found that dysfunctional HDL is better associated with CAD, independently of HDL levels or traditional risk factors across races.

• Future HDL-focused therapies need to account for an improvement in HDL function across races, in order to better combat health disparities in CAD.

• It is important to recognize that CAD burden also appears to differ in the heterogeneous Hispanic and Asian subgroups, where HDL cholesterol studies are sorely missing.

Notes