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Your total cholesterol and your LDL cholesterol have traditionally been considered the most important predictors of your risk for cardiovascular disease and are therefore most doctors’ primary focus when interpreting your cholesterol test. In addition to these numbers, your HDL and triglycerides are becoming more and more recognized as important risk factors, in and of themselves. But even more telling, according to the latest research, is your cholesterol ratio.
What Is Cholesterol Ratio?
Your cholesterol ratio is the ratio of your total cholesterol to your HDL (“good”) cholesterol level. Cholesterol ratio can be easily calculated and is often abbreviated TC/HDL-C. This ratio is so commonly used, and has been so extensively studied, that it is fairly routine for most labs to do the calculation for you and to report this along with your other cholesterol findings. Depending on what laboratory your doctor’s office uses, you may or may not see your cholesterol ratio reported along with your other results. To calculate it on your own, just divide your total cholesterol by your HDL. (For example, if your total cholesterol is 240 and your HDL is 38, then 240 ÷ 38 = 6.3 cholesterol ratio.)
What Cholesterol Numbers Tell Us
Why is total cholesterol:HDL cholesterol ratio better at predicting risk?
If you want to know what your standard cholesterol test says about your heart disease risk, it’s much better to look at these numbers than simply your total cholesterol or your LDL, according to the most recent studies. In fact, as astounding as it might sound, just having a high total cholesterol or LDL cholesterol does not necessarily mean you are at increased risk of heart disease.
A study of 3322 middle aged adults published in the Journal of the American Medical Association, for instance, found that while total cholesterol and LDL cholesterol were not associated with increased risk of coronary heart disease in any statistically significant way, the total cholesterol to HDL cholesterol ratio was.
The subjects, who were part of the famous Framingham Offspring Study, did not have any cardiovascular disease to start with. They were followed by the researchers for 15 years. The investigators tracked the subjects’ cholesterol and monitored them for events resulting from coronary heart disease (heart attacks, chest pain, “coronary insufficiency,” or death from heart disease). In the end, “the lipid ratios performed better than the individual lipids for risk prediction,” according to the study’s authors. While the total cholesterol:HDL-C ratio was associated in a statistically significant way to heart disease, total cholesterol and LDL cholesterol values were not.
Other studies have yielded similar results, indicating that total cholesterol:HDL cholesterol ratio is a better predictor of cardiovascular disease than other individual cholesterol values, especially total cholesterol.[2-3] And if you already have cardiovascular disease, you can lower the chances of it killing you by decreasing your cholesterol ratio.[4,5]
What Is an Optimal Cholesterol Ratio?
The optimum ratio of total cholesterol to HDL cholesterol is 3.5 (3.5:1) according to the American Heart Association. So if your total cholesterol is 200, you would need an HDL of at least 57 to achieve the optimal ratio of 3.5. Anything less than 3.5 is even better, while anything greater than 3.5 is considered a less-than-optimal cholesterol ratio, which increases your risk of cardiovascular disease.
More to the Cholesterol Story
Optimal LDL-lowering therapy alone fails to avert the majority of heart disease. It’s well known that lowering LDL cholesterol does, indeed, lower your risk for heart disease. But a sad fact is that despite the effectiveness of statin drugs for reducing heart disease risk, even optimal LDL-lowering therapy alone fails to stop 60% to 70% of coronary heart disease cases. Clearly, there’s more to heart disease than LDL cholesterol!
Luckily, by looking beyond just total and LDL cholesterol, you can use your cholesterol ratio from your standard cholesterol test to tell you a lot about your risk for developing heart disease and having a heart attack or stroke. To improve your ratio, either increase your HDL or lower your total cholesterol, or both. Achieving this ratio of 3.5 or less is quite doable for most people using natural healing therapies.
 Ingelsson E, Schaefer EJ, Contois JH, McNamara JR, Sullivan L, Keyes MJ, Pencina MJ, Schoonmaker C, Wilson PW, D’Agostino RB, Vasan RS. Clinical utility of different lipid measures for prediction of coronary heart disease in men and women. JAMA. 2007 Aug 15;298(7):776-85.
 Zhang L, Qiao Q, Tuomilehto J, et al; DECODE Study Group. The impact of dyslipidaemia on cardiovascular mortality in individuals without a prior history of diabetes in the DECODE Study. Atherosclerosis. 2009 Sep;206(1):298-302.
 Lemieux I, Lamarche B, Couillard C, et al. Total cholesterol/HDL cholesterol ratio vs LDL cholesterol/HDL cholesterol ratio as indices of ischemic heart disease risk in men: the Quebec Cardiovascular Study. Arch Intern Med. 2001 Dec 10-24;161(22):2685-92.
 Keil U, Liese AD, Hense HW, et al. Classical risk factors and their impact on incident non-fatal and fatal myocardial infarction and all-cause mortality in southern Germany. Results from the MONICA Augsburg cohort study 1984-1992. Monitoring Trends and Determinants in Cardiovascular Diseases. Eur Heart J. 1998 Aug;19(8):1197-207.
 Real JT, Chaves FJ, Martínez-Usó I, et al. Importance of HDL cholesterol levels and the total/ HDL cholesterol ratio as a risk factor for coronary heart disease in molecularly defined heterozygous familial hypercholesterolaemia. Eur Heart J. 2001 Mar;22(6):465-71.
 Gadi R, Amanullah A, Figueredo VM. HDL-C: Does it matter? An update on novel HDL-directed pharmaco-therapeutic strategies. Int J Cardiol. 2012 Jun 3. [Epub ahead of print] PubMed PMID: 22668801.
This post originally appeared in 2012 and is regularly updated.