Normal cholesterol panel . . . no heart disease?

I often hear this comment: "I have a normal cholesterol panel. So I have low risk for heart disease, right?"

While there's a germ of truth in the statement, there are many exceptions. Having "normal" cholesterol values is far from a guarantee that you won't drop over at your daughter's wedding or find yourself lying on a gurney at your nearest profit-center-for-health, aka hospital, heading for the cath lab.

Statistically, large populations do indeed show fewer heart attacks at the lower end of the curve for low total and  LDL cholesterol and the higher end of HDL. But that's on a population basis. When applied to a specific individual, population observations can fall apart. Heart attack can occur at the low risk end of the curve; no heart attack can occur at the high risk end of the curve.

First of all, to me a "normal" lipid panel is not adhering to the lax notion of "normal" specified in the lab's "reference range" drawn from population observations. Most labs, for instance, specify that an HDL cholesterol of 40 mg/dl or more and triglycerides of 150 mg/dl or less are in the normal ranges. However, heart disease can readily occur with normal values of, say, an HDL of 48 mg/dl and triglycerides of 125 mg/dl, both of which allow substantial small oxidation-prone LDL particles to develop. So "normal" may not be ideal or desirable. Look at any study comparing people with heart disease vs. those without, for instance: Typical HDLs in people with heart attacks are around 46 mg/dl, while HDLs in people without heart attacks typically average 48 mg/dl--there is nearly perfect overlap in the distribution curves.

There are also causes for heart disease that are not revealed by the lipid values. Lipoprotein(a), or Lp(a), is among the most important exceptions: You can have a heart attack, stroke, three stents or bypass surgery at age 40 even with spectacular lipid values if you have this genetically-determined condition. And it's not rare, since 11% of the population express it. How about people with the apo E2 genetic variation? These people tend to have normal fasting cholesterol values (if they have only one copy of E2, not two) but have extravagant abnormalities after they eat that contribute to risk. You won't know this from a standard cholesterol panel.

Vitamin D deficiency can be suggested by low HDL and omega-3 fatty acid deficiency suggested by higher triglycerides, but deficiencies of both can exist in severe degrees even with reasonably favorable ranges for both lipid values. Despite the recent inane comments by the Institute of Medicine committee, from what I've witnessed from replacing vitamin D to achieve serum 25-hydroxy vitamin D levels of 60-70 ng/ml, vitamin D deficiency is among the most powerful and correctable causes of heart disease I've ever seen. And, while greater quantities of omega-3 fatty acids from fish oil are associated with lower triglycerides, they are even better at reducing postprandial phenomena, i.e., the after-eating flood of lipoproteins like VLDL and chylomicron remnants, that underlie formation of much atherosclerotic plaque--but not revealed by fasting lipids.

I view standard cholesterol panels as the 1963 version of heart disease prediction. We've come a long way since then and we now have far better tools for prediction of heart attack. Yet the majority of physicians and the public still follow the outdated notion that a cholesterol panel is sufficient to predict your heart's future. Nostalgic, quaint perhaps, but as outdated as transistor radios and prime time acts on the Ed Sullivan show.


Comments (19) -

  • Might-o'chondri-AL

    6/15/2011 4:14:41 PM |

    I  was surprised that in order to get my  vitamin D25 level to 58.3 ng/mL  this winter in southern California I had to take 6,000 IU daily  of vitamin D3;  as was outside in short sleeves a fair spell every day.   This was first time where could test,  and my first time supplementing as well;  now am using at least 7,000 IU daily of vitamin D3 and it's summer months.

    Set my blind trial dose,   as a precaution, on low side based on info read here (from T. Hutchinson) suggesting 1,000 IU D3 for every 25 pounds body weight;  I had no clue what my baseline D3 was . Used  glycerin drops from Vitality Works out of New Mexico,  where 5 drops = 2,000 IU D3 ;  I've no financial interest in this.

    All males on my paternal side died from heart related problems before their late 50's so went ahead and tested my Lp(a) a while back;  I got clued in to Lp(a) by reading Doc's posts here . Was pleased and relieved to see a Lp(a) reading of just 2 , since lab gives less than 20 Lp(a) as normal.

  • Jimmy

    6/16/2011 12:07:56 AM |

    Then how is Lp(a) best treated?
    I am 36 and have had high Lp(a) for 16 years now. It sits near 100. That with low HDL and high LDL I feel like a walking time bomb. My father passed at 44 and mom at 46 and all uncles on mom's side dead prior to 50 of heart disease. Father was adopted, so do not know his side. What is worse, is that I have just relocated to Toronto, Canada (from the US) and I cannot find a doctor who even acknowledges what Lp(a) is. Nor can I find one (and I have been searching for 2 years) who thinks my cholesterol is high enough to "worry about".  It's even worse here than in my small town back in the US as far as getting decent lipid testing and advice Frown     Sorry to rant.

  • Lora

    6/16/2011 1:33:58 AM |

    I'm glad that you are warning people with normal cholesterol panels not to be complacent about their arterial status. My  cholesterol totals from age 40 to 52  ranged between 114 and 132.  My HDLs in my late 40s/early 50s were 64, 58, 53; LDLs 55, 56, 48; triglycerides 66, 49, 70.  The cholesterol totals on the latter two panels were below the normal range, which I've read can be problematic, though that's a topic that it is very difficult to find info about. What a surprise to get an severely infected blister on my foot, complicated by poor circulation, and to subsequently be found to have "mild arteriosclerotic changes" in my lower extremities.  I wonder about the mildness b/c now I perceive the dramatically decreased amount of hair on my legs as an indicator of poor circulation.

  • Dr. William Davis

    6/16/2011 11:54:41 AM |


    Please do not accept the advice offered by many of my colleagues that there is no treatment for Lp(a), or that the only treatment is to reduce LDL to less than 80 mg/dl with statins. All nonsense.

    Undoubtedly, the science behind Lp(a) is still unfolding and is proving to be more complex than initially thought. For instance, newer observations are suggesting that the atherogenic (plaque-causing) potential of Lp(a) may be largely due to its oxidized phospholipid and phospholipase A2 content.

    Nonetheless, I urge you  to participate in our discussions on the Track Your Plaque website, where you will find extensive reports and discussions on what to do with Lp(a). Our current first treatment of choice is high-dose fish oil, i.e., 6000 mg per day EPA + DHA.

  • Dr. William Davis

    6/16/2011 11:56:51 AM |

    Hi, Lora--

    Clearly, your answers won't be found in cholesterol values. This is far more common than often thought.

    Look for Lp(a), small LDL, vitamin D deficiency, and consider omega-3 fatty acid supplementation. Consider unappreciated hypertension and endogenous glycation, i. e, high HbA1c.

  • James

    6/16/2011 8:22:33 PM |

    When I got my in-office lipid panel results, my doctor was pleased by the results (I was too):

    Trigs: 50
    Total Chol: 198
    HDL-C: 70
    LDL-C: 118 (slightly elevated)

    That gives me a TC/H of 2.8, which I assume is excellent.

    BUT, I also got a NMR LipoProfile test, and here were those results:
    LDL-P: 1410 (High)
    Small LDL-P: 613 (High)
    Vit D: 31.4 (Low)

    I was surprised that the NMR test revealed some risk, while my standard panel did not. My doctor now wants to test me again in 4 months.

  • kenneth

    6/17/2011 1:39:19 PM |

    I've never been able to get my HDL above 36 (it's as low as 25). Triglycerides in me and my brother run 400-500 uncontrolled (neither of us is at all obese). I'm at 8 grams of fish oil now, 1 g of IR niacin and I've bumped up my Vitamin D to 8,000 a day, and I'm hoping that makes a difference at least with the HDL. My LDL and total cholesterol numbers are "normal" although god knows what a VAP or NMR would reveal. Would I be crazy to think about adding a bit of statin to this mix, ie 10 mg/day of atorvastatin or simvistatin? Has anyone had any luck with sytrinol or anything else? I'm not wheat free I know, but I have cut way down.

  • Anand

    6/17/2011 4:23:50 PM |

    Dr. Davis,
    What is your take on the AIM-HIGH trial ?
    My Lpa, measured at Berkeley is extremely elevated at 190 mg/ dl. Their assay is supposed to be isoform insensitive. I am on 20 mg crestor and 2 g niaspan along with 2g carnitine, 2500 IU vitamin d (level is 36) and 3 g EPA plus DHA.
    I do follow a low carb diet.
    I also have FH. Untreated my TC was 300 with LDL over 200.  I already have one stent in mid LAD despite being thin (BMI 23).
    I am wondering how to monitor my coronary arteries besides the standard stress test.

    An and

  • Lora

    6/17/2011 8:32:43 PM |

    Thank you for the information. My HbA1c when checked was 5.6. I had already started cutting back significantly on carbs a couple of weeks before that. I think endogenous glycation has been a significant factor for me. I've avoided white sugar for many years, but I used to quite frequently eat beans and whole grains, including whole grain oatmeal every morning. I discovered with a OneTouch UltraMini glucose monitor that my BG went into the 170s after eating that!  I haven't found any other food that sends my BG so high.  (And  I used to frequently eat the oatmeal along with fruit!) An hour after the drink in a glucose tolerance test my BG was 138 (then went to 79 an hour later).  My vitamin D when checked was 43.6 so not terrible, but showing room for improvement. I'ave been taking Member's Mark fish oil (which I read about on this web site) for quite awhile, but I’d been somewhat erratic with it before realizing my problem. I have a variant of "white coat" hypertension, which I've read is probably more harmful than it was once thought to be. Normally my BP is on the low side but stressful situations sometimes cause it to spike dramatically. My BMI has been 20 for years, used to be lower. I've never smoked. I wonder about carnitine b/c my diet has been largely, though not entirely, vegetarian for years. I definitely haven’t been getting enough exercise. Also, I've come across journal articles about Type D personality traits and think they may be a factor.  I have to get Lp(a), small LDL, and other sub-elements checked.    

    Thanks again! I have learned a lot from this web site.

  • Helen

    6/20/2011 7:11:33 PM |

    Lora -

    Yikes!  You sound almost exactly like me.  I don't really know what to do about the glucose spikes.  Low carb didn't help me.  I'm not trying to burst Dr. Davis' bubble or anything, just saying what was true for me.  Fish oil and niacin make my blood sugar spike more.  My blood pressure and resting heart rate are low, though.  Only occasionally do I get the white coat hypertension thing.  But otherwise, my cholesterol panel and blood sugar experiences mirror yours pretty well.

  • Lora

    6/22/2011 7:43:10 PM |


    Fortunately, decreasing or avoiding certain carbs does help me control my blood glucose. I bought a glucose monitor, as suggested by Dr. Davis. Ironically, I have discovered that some of the foods I used to make it a point to eat for health reasons (oatmeal, apple) spike my blood sugar the most.

  • SK

    6/25/2011 2:27:20 PM |

    We are big fans of fish oil.

    BUT, now we read this: "our findings are disconcerting as they suggest that ω-3 fatty acids, considered beneficial for coronary artery disease prevention, may increase high-grade prostate cancer risk, whereas trans-fatty acids, considered harmful, may reduce high-grade prostate cancer risk. " ???


  • SK

    6/25/2011 2:31:28 PM |


    my mistake. let me post this at the right blog topic....

  • Gregory

    6/27/2011 1:34:08 AM |


    I too: a cup of muesli and fruit for breakfast for years. One day I tested: 179 after 1 hour. I now try to aim for 1 hr post prandial 110. No more muesli and fruit for breakfast!

  • Dr. Hasitha Dissanayake

    7/1/2011 5:02:37 PM |

    Dr. Davis, you have nicely described the high lipid levels and its impact on heart disease. Yes, as you have described the hight lipid level is not the only cause for heart diseases. Other major risk factors include smoking, hypertension and  diabetes. Further there are also number of minor risk factors for heart diseases as well, such as family history, sedentary life style, male gender etc.

    We should not make our minds by looking only at normal cholesterol panel. As you have described already vitamin D in important to produce more HDL and Omega-3 fatty acids. Any way vitamin A, C and E act as anti oxidants and also reduce the cancer risk. Visit

    Nice blog Dr. Davis... Keep on writing...

  • John

    7/21/2011 6:16:28 PM |

    WOW! all these numbers/letters and i've not a clue what most of them mean! i'm aware of the hdl/ldl numbers/levels , though not of the others. i happened across this site/blog from another nd/md's blog and i find this stuff to be mind-boggling! my health challenge: Late Nov. 2010, i had a stent placed in a major artery that i'm told was 90-95% blocked. while recovering in cath lab, i almost bled to death with a hemotopa ( ? ) the size of an orange, i was told upon my discharge by the nurse who saw it and literally saved my life. i've since been on plavix 75mg, 1x/day in which i've chosen to cut these in half and now take 1/2 pill at 12+ hours intervals or when i suddenly feel tired, pains and get scared. i should also tell you i've been diagnosed w/ peripheral neuropathy and experience many different types of stinging/pinching pain in various parts of by body. doing alot of computer work ( i work from home on the internety ) with one=finger hunt-n-pek typing also causes numbness and pain in my right hand. the very first day after the procedure,  i was given 7 - yes, 7! - plavix75mg. needless to say, the ensuing 4 weeks was hell for me and out of fear, i was back and forth to a heart hospital about 4 different ocassions. my entire right leg, groin, testacles and penis was purple/bluish and bruised. Now, i have not felt good since this stent was put in. i feel that the other type stent could have been used instead of the drug-alluding stent. I was also prescibed a statin of which I've NOT taken since finding out how ineffective and dangerous they are and that we actually need cholesterol especially for prpoer brain functioning. as i type now, i'm in discomfort. i recently started drinking a organic magnesium supplement called Natural Calm but aside from it cleaning me out, i feel no better at this point. I NEED HELP! i'm depressed and very irritable over the smallest things, at times. I have attempted to follow Dr. D'adamo's Eat right For your Blood type diet, but, since these supplements can be quite expensive ( i'm on a S.S. disability for Tourettes Syndrome ) i don't take them as often as i should so i really can't say whether or not they help. i've eaten breads my entire life and pizza as and still is my favorite ( i'm italian of course-Smile basically, i've been eating all foods my entire life that i shouldn't have been. i'm driving my wife and myself crazy and she does return the "favor' quite often. so now i read all this info. about vit. D and fish oils and i'm more confused than ever. being in NY, i'm aware of the vit. d ( lack of ) in relation to depression or SAD, etc.  i'm praying i find some nd/md who is willing and able to work with me to get me off this plavix and gabapentin 300mg ( 3 caps, 2x per day or as i feel they are needed ). my cardi says that after 1 year he'll be able to take me off the plavix, but, honestly, i feel this drug is killing me. oh...i also have the beginnings of Barretts Esophagus ( very small, i'm told ) and my gastro and cardi feel the combination of Plavix 75mg, Protonix 40mg, enteric coated Reg. strength aspirin ( of which i take 1-2  Baby aspirin instead, very rarely ),
    gabapentin 300mg is safe for me and outweighs the 30% or so possibility of having a blood clot at the stent. I've also thin blood to begin with ( type 0+ ) and i'm just feeling miserable! i do have a good day here and there, but mostly my days are spent very uncomfortable, irratable, depressed, tired and angry. I used to be healthy and exercised but now if i get out to walk a while, that's about it. i've never weighed in at more than 185 with much of my life weighing between 155-170. i am 5'7" and had always been considered to have broad shoulders and was husky as a young child. i'm hoping to get some relief and my good health back. i thank you for reading this and letting me vent. i apologize for any typos and the inconsistencies.

  • Lawrence

    9/30/2011 12:38:03 PM |

    Dear Dr William Davis
    In May of 2009 my wife had a brain aneurism and stroke.  (Then 52)
    Two years on she is extremely well due to a very skilled neurosurgeon. It has come to light that my wife has type 2 diabetes, high blood pressure and high cholesterol.
    Her medications are 1000mg of Metformin twice daily with meals.
    160mg of Diovan  mornings.
    25 mg HCTZ mornings.
    We are supplementing her meds with 1000mg of fish oil and now 2000iu of Vitamin D.
    A month ago we started using the Heart Technology Heart Tech formula two scoops  a day.
    Approx one month after starting the Heart Tech Formula my wife has had some blood work done.
    The results are as follows:
    A1C 7.1
    Lipoprotein A 23 nmol/L
    Vitamin D, 25 Hydroxy (vd25)  33ng/ml.
    C-reactive Protein HS 0.80 mg/dl.
    Cholesterol 236 md/dl.
    HDL 48 mg/dl.
    Triglyceride  181 mg/dl.
    VLDL  36 mg/dl.
    LDL 152 mg/dl.
    Non –HDL  188
    LDL/HDL ratio 3.17.
    My wife was originally taking Simvastain 25mg per day but our PCP stopped this due to some nasty side effects, he has since suggested we start  Lipitor, but after reading so many worrying articles regarding Lipitor and other statin usage  we are very reluctant to start using the Lipitor.
    I wonder if you would mind discussing our options and what you would consider my wife’s risk of Heart Attack and stroke are and if you feel the use of vitamin C, lysine etc in the Heart Tech will help with her risk.  I am new to the site so have not found my way around yet.
    Thank you.

  • Dr. William Davis

    10/1/2011 2:04:52 PM |

    Hi, Lawrence--

    I would strongly urge you and your wife to 1) read the many posts on this blog about the exact situation your wife is experiencing and, 2) if interested in more information, consider going to the Track Your Plaque website, where many discussions are conducted on these issues every day.

    Your wife's pattern is a clear-cut example of carbohydrate excess and/or genetic susceptibility and vitamin D deficiency. All of this is readily, easily, and safety correctable with no drugs.

  • Lawrence

    10/1/2011 9:33:03 PM |

    Dear Dr William Davis
    I suppose in some ways being diagnosed with type 2 has been a good thing, in spite of my wife mild brain damage she is starting to realize that she has to cut out all the rapid acting carbohydrates that she used to exist on. It has taken me some time to find the right approach to helping control her BG, but she is now starting to see the better BG reading so is responding to the good feedback. We are increasing our dose of Vitamin D3 to 10000 IU.  We plan to continue with the Heart Tech, my feeling is her LPa would have been much higher if she had not had a month of the Heart Tech formula prior to her blood draw.
    I will certainly log in to Track Your Plague, thank you for taking the time to respond to my questions, it’s very reassuring that you feel she will respond to the Track Your Plaque.