Abstract-A low level of high-density lipoprotein cholesterol (HDL-C) is an important risk factor for cardiovascular disease. Epidemiological and clinical studies provide evidence that HDL-C levels are linked to rates of coronary events. The cardioprotective effects of HDL-C have been attributed to its role in reverse cholesterol transport, its effects on endothelial cells, and its antioxidant activity. Although some clinical trials suggest a benefit of raising HDL-C to reduce risk, further studies are needed, and HDL-C is still not considered a primary target of therapy in the National Cholesterol Education Program guidelines. However, HDL-C should be considered as part of the patient's overall profile of established risk factors in determining treatment strategies. T he association between low levels of high-density lipoprotein cholesterol (HDL-C) and an increased risk for cardiovascular disease has been well established through epidemiological and clinical studies. 1 This relationship is supported by the potential antiatherogenic properties of HDL, including its mediation of reverse cholesterol transport, in which cholesterol from peripheral tissues is returned to the liver for excretion in the bile. 2 This review considers the potential mechanisms by which HDL-C may exert its antiatherogenic effects, discusses disorders of HDL and how to interpret them in the clinical setting, and presents current and potential treatment strategies for patients with low HDL-C.
Structure and Metabolism of HDL and Relation to Potential Mechanisms of BenefitOverview of HDL Structure and Heterogeneity HDL is a class of heterogeneous lipoproteins containing approximately equal amounts of lipid and protein. 1 HDL particles are characterized by high density (Ͼ1.063 g/mL) and small size (Stoke's diameter ϭ5 to 17 nm). The various HDL subclasses vary in quantitative and qualitative content of lipids, apolipoproteins, enzymes, and lipid transfer proteins, resulting in differences in shape, density, size, charge, and antigenicity. Most of apolipoprotein A-I (apo A-I), the predominant HDL protein, migrates in agarose gels with ␣-electrophoretic mobility and is designated ␣-LpA-I. This fraction accounts for almost all of the cholesterol quantified in the clinical laboratory as HDL-C. ␣-HDL can be further fractionated by density into HDL 2 and HDL 3 , by size, or by apolipoprotein composition. Approximately 5% to 15% of apo A-I in human plasma is associated with particles with pre--electrophoretic mobility. These can be further differentiated into pre- 1 -LpA-I, pre- 2 -LpA-I, and pre- 3 -LpA-I particles. These lipid-poor particles are increased in extravascular compartments where reverse cholesterol transport takes place. 3 The origin of HDL particles with pre--electrophoretic mobility is not entirely clear. Several mechanisms have been proposed, including direct secretion into plasma from hepatocytes or enterocytes; release during the interconversion of various HDL subpopulations by phospholipid transfer protein (PLTP), cholesteryl ...