EP384: Will Your HDL Save You?

Welcome to my podcast. I am Doctor Warrick Bishop, and I want to help you to live as well as possible for as long as possible. I’m a practising cardiologist, best-selling author, keynote speaker, and the creator of The Healthy Heart Network. I have over 20 years as a specialist cardiologist and a private practice of over 10,000 patients. Podcast Summary Introduction Dr. Warrick Bishop, a cardiologist, author, keynote speaker, and CEO of the Healthy Heart Network, hosts this episode to help people understand cardiovascular health. In this episode, Dr. Bishop challenges a common misconception about HDL cholesterol, explaining that having "good" HDL levels alone does not guarantee cardiovascular protection and may not be as beneficial as many patients and doctors believe. Key Takeaways: Cholesterol exists as molecules in cells and also travels through the bloodstream in particles called lipoproteins, which are categorized by their protein types: ApoB (harmful) and ApoA (protective). ApoB particles carry "bad" cholesterol (LDL) and create environments for plaque formation, while ApoA particles carry HDL "good" cholesterol and theoretically transport cholesterol back to the liver through reverse transport. The total cholesterol-to-HDL ratio in many risk calculators may primarily reflect the amount of harmful ApoB cholesterol present rather than revealing any special protective benefits of HDL itself. Research shows a U-shaped curve relationship with HDL levels, where both very low and very high HDL levels are associated with increased cardiovascular risk, indicating the relationship is far more complex than "higher is better." Multiple clinical trials using different agents (niacin, fibrates, CETP inhibitors, and even infused ApoA1) have raised HDL levels but failed to demonstrate reduced cardiovascular disease risk, challenging the protective HDL hypothesis. The primary cardiovascular risk driver appears to be exposure to ApoB particles and their associated cholesterol rather than HDL levels, suggesting doctors should focus on lowering harmful particle count rather than reassuring patients based on HDL alone. Having high HDL cholesterol alone should not provide false confidence; patients should not assume they are protected from heart disease based solely on favorable HDL readings. HDL is an extremely complex molecule and transport mechanism with significant individual variability, making it inappropriate to view it as a simple, one-dimensional "good cholesterol" marker.