A 44-year-old male patient balked at making any lifestyle changes to lower his elevated LDL (the so-called "bad") cholesterol.

I mentioned his bad family history: His older brother and father both had heart attacks in their late 40s. His rebuttal was that his blood pressure was excellent, he didn't smoke, his blood sugar was normal, and he wasn't overweight. Mostly, he felt safe from a heart attack because his HDL (or "good") cholesterol of 62 mg/dL was so high.

It's true that many studies have shown the protective effects of high HDL cholesterol, and the National Cholesterol Education Program (NCEP) guidelines state that an HDL cholesterol of 60 mg/dL or higher can negate one risk factor, such as a bad family history or cigarette smoking.

While I recognize that a high HDL cholesterol level may be a strong defense against heart attacks, I don't agree with the NCEP that HDL cholesterol of 62 mg/dL is enough to counter the ill effects of smoking or a bad family history. Just like other physicians, I have seen my share of heart attacks in men with an HDL cholesterol of 70 mg/dL or higher.

In addition, the HDL cholesterol level is determined largely by genetic factors, so there is a reasonable chance that his father and brother also had high HDL cholesterol levels and yet suffered heart attacks.

Decisions on when to lower LDL cholesterol are based on the number of risk factors and the level of the LDL cholesterol. This man has either one risk factor, using my approach, or no risk factors, according to the NCEP guidelines. In either case, I believe his LDL cholesterol of 175 mg/dL warrants an effort to lower it with dietary measures such as eating foods low in saturated fat and cholesterol.

I'm less certain whether he should be treated with a cholesterol-lowering medication, but I told my brother, when he was in similar circumstances, to start taking a statin.