My recent physical showed I have an HDL level of 99. My cholesterol level is 239, up from 220 last year in spite of a healthy diet. Should I be on a cholesterol-lowering drug? 
— Carolyn, Ohio
The good news, Carolyn, is that your protective high-density lipoprotein cholesterol (HDL) is considerably higher than the National Cholesterol Education Program (NCEP) guideline of 60 mg/dl for both women and men. It's likely that your somewhat high total cholesterolnumber reflects your high good cholesterol, and that your ratio of HDL to LDL (the bad low-density lipoprotein cholesterol) is good. That said, if you are postmenopausal, high HDL on its own is not always protective.
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One of the problems with doing the most basic lab blood test for evaluating cardiac risk (the standard lipid profle) in a doctor's office is that the results only tell you your total HDL and LDL and not the size of these particles. And what many people don't know is that size does matter when it comes to both. The smaller and denser your LDL particles, the greater your chance for a heart attack. This is because these smaller and denser particles move through the inner cell lining of your arteries (the endothelium) more efficiently, depositing more cholesterol and creating more plaque. Likewise, the smaller your HDL particles, the less protective they are. If you have large HDL particles, it shows that cholesterol is being successfully transported back to your liver for excretion. What I've found is that if a person has high HDL, as you do, the particles are almost always large. In such cases, I generally prescribe diet and lifestyle changes, including plenty of exercise, rather than a statin.
For those with low or borderline HDL, I often recommend an advanced blood test known as alipoprotein subfraction test, which shows the size of the person's HDL and LDL. If the test finds that the individual has large-particle HDL (in combination with high total HDL), as well as large-particle LDL, then it is unlikely that the person would need a statin drug.
Another test I often do to determine whether or not to treat someone with cholesterol-lowering medications is carotid artery ultrasound, which measures the thickness of the inner lining of the carotid arteries (the arteries that run under the skin on each side of the neck and carry blood to the brain). The measurement is called intimal medial thickness, and it is a good predictor of early onset atherosclerosis, or "hardening of the arteries." If the results show thickening, or if there is moderate or high risk of heart disease based on overall risk factors, then I also recommend that the patient get aheart scan for coronary calcium, which measures the amount of calcified plaque in the coronary arteries and indicates the degree of atherosclerosis present.
While some of these more advanced tests may not be covered by health insurance, they are well worth the cost, especially if it means avoiding a statin and feeling reassured about your cardiac health. Looking at your numbers, though, it looks to me as though you don't need these advanced tests. However, they are certainly worth discussing with your own doctor.