High-density lipoprotein cholesterol levels as a marker of reverse cholesterol transport.

Dramatic advances have been made over the last decade in understanding the role of low-density lipoprotein (LDL) in atherosclerotic cardiovascular diseases and how to manage elevated levels of LDL cholesterol. Understanding the role of high-density lipoprotein (HDL) and how to intervene therapeutically in HDL action offers the possibility of even greater benefits. Epidemiologic studies have shown a strong inverse relation between HDL cholesterol and the risk of coronary artery disease (CAD). Whereas several subfractions of HDL can be identified, none convincingly offers better predictive value than total HDL cholesterol. Apolipoprotein A-I, the major apolipoprotein of HDL, also is inversely related to atherosclerotic risk. Unfortunately, measurements of HDL cholesterol or apolipoprotein A-I are considerably less precise and less accurate than measurements of total or LDL cholesterol. The biologic phenomena responsible for these epidemiologic relations are not yet clear. Moreover, several apparently contradictory observations and puzzling exceptions to the simplistic inverse relation of HDL cholesterol to CAD suggested by epidemiologic studies have created considerable confusion. The current confusion is not likely to be resolved until HDL metabolism and the cellular and molecular events responsible for the apparent protective effects of HDL are better understood. One current hypothesis that could explain the protective effects of HDL is that it mediates reverse cholesterol transport, the process by which cholesterol is removed from sites of deposition and delivered to the liver for excretion. From the standpoint of current therapy, each intervention that changes HDL cholesterol levels must be evaluated individually, on its own merit, in light of its effect on atherosclerosis and coronary events rather than on alterations in HDL cholesterol levels.(ABSTRACT TRUNCATED AT 250 WORDS)