There is now strong evidence that the risk of developing clinical coronary heart disease (CHD) in apparently healthy middle-aged men is inversely related to the plasma high density lipoprotein (HDL) cholesterol concentration. This reflects an underlying relationship between HDL cholesterol concentration and the severity of coronary atherosclerosis. This new information represents a significant development in atherosclerosis research. In the author's opinion, however, it is not yet justifiable, or indeed possible, to utilize this knowledge in CHD prevention programmes for 3 reasons. Firstly, there is still little prospective information on HDL and CHD in women, in younger subjects and in patients with existing clinical disease. Secondly, although there are at least 2 working hypotheses, a causal relationship between HDL metabolism and atherogenesis has not yet been established. Thirdly, there is still a relative paucity of information on the environmental determinants of HDL concentration and metabolism. Thus, premature attempts at intervention in an uncontrolled manner, and particularly the use of drugs for an HDL-raising effect, might only confuse the issue. While further research is being undertaken, attention should continue to be directed towards other reversible coronary risk factors (including hypercholesterolaemia, hypertension, and cigarette smoking) in CHD prevention programmes.
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