What should I look at on a lipid panel besides LDL?

A standard lipid panel reports total cholesterol, LDL cholesterol, HDL cholesterol and triglycerides. LDL gets the attention, but two people with the same LDL can carry very different risk, and the rest of the panel is where that difference shows. The 2018 AHA/ACC cholesterol guideline formalised this by listing risk-enhancing factors that shift a borderline decision about treatment, several of which are already printed on a routine report or can be calculated from it.

Non-HDL cholesterol, calculated free

Non-HDL cholesterol is total cholesterol minus HDL cholesterol. It captures every cholesterol-carrying particle that can deposit in an artery wall rather than LDL alone, which makes it more informative when triglycerides are raised. It requires no extra blood and no extra cost, because both numbers are already on the panel. The 2018 guideline lists a non-HDL cholesterol of 190 to 219 mg/dL among the features of primary hypercholesterolaemia that act as risk-enhancing factors.

Triglycerides and the metabolic pattern

The 2018 guideline treats persistently elevated triglycerides of 175 mg/dL or above as a risk-enhancing factor. In a metabolic practice, raised triglycerides with a low HDL is the pattern that most often signals insulin resistance, and it usually appears years before glucose becomes abnormal. Fasting is not required for routine testing: the 2016 joint consensus statement from the European Atherosclerosis Society and the European Federation of Clinical Chemistry recommends non-fasting lipid profiles for most patients, with a fasting repeat considered if non-fasting triglycerides exceed 440 mg/dL.

The markers that change borderline decisions

Three additional measurements are listed by the 2018 guideline as risk-enhancing when measured: high-sensitivity CRP of 2.0 mg/L or above, lipoprotein(a) of 50 mg/dL or 125 nmol/L or above, and apolipoprotein B of 130 mg/dL or above, which corresponds to an LDL cholesterol of about 160 mg/dL. The guideline gives a relative indication for measuring apolipoprotein B when triglycerides are 200 mg/dL or higher. These are not routine screening tests for everyone; they are tools for deciding when the statin decision is genuinely close.

Take your last lipid panel and calculate non-HDL cholesterol yourself: total cholesterol minus HDL. If it is high while your LDL looks acceptable, that is worth raising. If you have a family history of heart attack or stroke before the age of 55 in men or 65 in women, ask about lipoprotein(a) once and apolipoprotein B when triglycerides are raised.