Lipids – Heart Healthy Toolbox

A complement to other PCNA resources, this healthcare provider tool focuses on non-HDL-C: how it is determined, and recommendations for treatment based on risk categories.

Components

You can also view all sections of the Heart Healthy Toolbox.

For Patients

Lipoprotein(a): Your Levels Matter

For Providers

Non-HDL-C=Total Cholesterol Minus HDL-C (also available below)
Lipoprotein(a): Links to CVD Risk (also avaliable below)

Non-HDL-C = Total Cholesterol Minus HDL-C

The sum of Very Low-Density Lipoprotein (VLDL) + LDL cholesterol is called non-HDL cholesterol. It is calculated routinely as total cholesterol minus HDL cholesterol. In persons aged 20 and older with elevated triglycerides (TG)of 175-499 mg/dL, most cholesterol occurring in the VLDL fraction is contained in the remnant VLDL, which is thought to be very atherogenic. The non-HDL-C level includes cholesterol carried in several atherogenic lipoproteins, such as LDL, very low-density lipoprotein (VLDL), intermediate-density lipoprotein (IDL), and lipoprotein(a) (Lp(a)).

Therefore, in patients aged 20 and older with elevated TG levels, 175-499 mg/dL, the class I recommendation includes identifying and treating secondary factors (lifestyle, secondary disorders, and/or medication).

The class IIa recommendation for ages 40-75 with severe hypertriglyceridemia >500 mg/dL with an ASCVD risk of ≥7.5% for whom secondary factors (above) have been addressed; it identifies persistently elevated TG as a risk enhancer which favors initiation or intensification
of statin therapy to reduce ASCVD risk.

Another class IIa recommendation is for those with TG ≥ 1,000 addresses many factors traditionally discussed in the management of hypertriglyceridemia.

Comparison of LDL Cholesterol and Non-HDL Cholesterol Goals for Three Risk Categories

RISK CATEGORY	LDL GOAL (MG/DL)	NON-HDL GOAL (MG/DL)
Multiple (2+) Risk Factors and 10-year risk ≤ 20%	< 130	< 160
0-1 Risk Factor	< 160	< 190
CHD and CHD Risk Equivalents (10-year risk for CHD > 20%)	Optional < 70 < 100	< 100 < 130

National Cholesterol Guidelines

Grundy SM, Stone NJ, Bailey AL. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Journal of the American College of Cardiology, 2019; 73(24):3168–3209. doi.org/10.1016/j.jacc.2018.11.002
Total and HDL Levels in US Adults 2021-2023 Carroll MD, Fryar CD, Bwira JA, Iniguez M. Total and High-density Lipoprotein Cholesterol in Adults: United States, August 2021-August 2023. (PDF) NCHS Data Brief. 2024. Accessed July 18, 2025.

10-YEAR RISK ASSESSMENT TOOL

ASCVD Risk Estimator, American College of Cardiology. tools.acc.org/ascvd-risk-estimator-plus/#!/calculate/estimate/
PREVENT Online Calculator, American Heart Association. professional.heart.org/en/guidelines-and-statements/prevent-calculator
Understanding Your Risk for Heart Disease and Stroke Fact Sheet, Preventive Cardiovascular Nurses Association. pcna.net/resource/understanding- your-risk-for-heart-disease-and-stroke-fact-sheet/
For Lipid Reference Values, visit NIH’s Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults

Lipoprotien(a): Links to CVD Risk

Lp(a) is composed of a cholesterol-laden LDL-like particle bound to a plasminogen-like glycoprotein, apolipoprotein(a).

Lp(a) is considered an independent risk factor for heart disease. It is also linked to an increased risk of stroke. Recently, elevated levels of Lp(a) have been linked as a risk factor for atherosclerotic cardiovascular disease (ASCVE), calcific aortic valve disease (aortic stenosis), and stroke.

The dual structure suggests that Lp(a) may be able to contribute to both atherosclerosis and thrombosis, and recent human genetic data support a role for Lp(a) in atherosclerotic stenosis in particular. This is no small impact, as atherosclerosis is attributed as the underlying cause of up to 50% of deaths in westernized society, while thromboembolic events are attributed to 1 in 4 of deaths worldwide.

Lp(a): Details for Patients

Many patients understand low-density lipoprotein cholesterol (LDL-C) but may not be familiar with Lp(a).

When speaking with patients about Lp(a), it may be helpful to describe it in terms such as “Think about Lp(a) as a cousin to LDL-C. Elevated levels of each can lead to an increased risk for heart attack, stroke, aortic stenosis, and other issues.”

Using clinical resources such as PCNA’s infographic, Lipoprotein(a): Your Level Matters may aid in improved understanding by patients, family members and caregivers.

Lp(a): Prevalence and Testing

While a growing number of people may know their levels of LDL-C, and perhaps their triglycerides, knowledge about Lp(a) is lacking. An estimated 1 in 5 people worldwide have elevated Lp(a), yet most of them are unaware. This lack of information not only puts individuals at greater risk for cardiovascular disease, but also family members who may also carry this genetically-influenced increased risk.

Lp(a) is measured using a specific blood test that is not part of a standard lipid panel. It is important to note that individuals may have normal levels of LDL-C and simultaneously high levels of Lp(a).

Measuring Lp(a) levels at least once in an individual’s lifetime helps to identify their unique risk for heart disease. Elevated Lp(a) can contribute to increased plaque accumulation, which may lead to narrowing of blood vessels, increased blood pressure, and increased risk for heart attack and stroke. Research indicates that there is more variability in Lp(a) levels over a person’s lifetime that previously identified, and there may be need for additional testing.

Lp(a) may be measured in either nmol/L or mg/dL units; nmol/L is often the preferred unit. Elevated Lp(a) levels are those >75 nmol/L (>30 mg/dL); high levels are >125 nmol/L (> 50 mg/dL).

While testing rates are increasing slightly, they still fall short in helping patients and health care professionals identify this important risk factor. The results of a recent study indicated that only 0.1% of adults in a cohort of 71 million individuals had ever been tested—yet the prevalence of elevated Lp(a) in the cohort was 21.4%.

Testing recommendations include individuals with personal or family history of ASCVD that is not fully explained by major CVD risk factors. Identification of elevated Lp(a) is also an important genetic marker to share so that other family members can be effectively screened and treated.

Lp(a): Management and Treatment

For individuals with abnormal levels of Lp(a), it is important to address and control all other heart-related risk factors. Examples include cholesterol-lowering medications (e.g., statins, etc.) and aiming for LDL-C levels of <100 mg/dL for those with no history of CVD. For those with CVD, aim for levels <70 mg/dL, and a level of <55 mg/dL should be the goal for people with heart disease and other cardiac risk factors.

Heart-healthy lifestyle factors such as tobacco cessation, healthy eating, staying active, decreasing stress, attaining/maintaining a healthy weight, etc. are an important part of reducing overall risk for CVD.

There may be some benefit for aspirin in individuals with Lp(a), particularly for those with levels >125nmol/L or 50mg/dL.

Lipoprotein apheresis is currently the only therapy with FDA approval for treating Lp(a) and is only available if an individual has familial hypercholesterolemia (FH) and specific levels of LDL-C and other factors. (See AHA statement for details.) While effective, the treatment is short-term and must be repeated regularly to keep Lp(a) levels low.

While there are currently no specific medications to lower Lp(a) levels, there are some promising therapies on the horizon. Stay tuned to pcna.net for more details as they become available.