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Quick Reference
  • Calculation: Non-HDL Cholesterol = Total Cholesterol - HDL Cholesterol
  • Desirable: <130 mg/dL
  • Borderline High: 130-159 mg/dL
  • High: 160-189 mg/dL
  • Very High: ≥190 mg/dL
  • Primary Use: Secondary lipid target (after LDL); useful when triglycerides elevated or non-fasting sample
  • Sample Type: Serum or plasma - NO FASTING REQUIRED
  • Key Point: Goal is typically 30 mg/dL above LDL goal; valid even when triglycerides >400 mg/dL

Test Description

What is Non-HDL Cholesterol?

Non-HDL cholesterol is a calculated value representing all cholesterol contained in atherogenic (artery-clogging) lipoproteins. It is simply total cholesterol minus HDL cholesterol.

Calculation:
Non-HDL Cholesterol = Total Cholesterol - HDL Cholesterol

Example:
Total Cholesterol = 220 mg/dL
HDL Cholesterol = 50 mg/dL
Non-HDL Cholesterol = 220 - 50 = 170 mg/dL

What Does Non-HDL Cholesterol Represent?

Non-HDL cholesterol encompasses all cholesterol-carrying particles except HDL - essentially, all the "bad" cholesterol particles:

  • LDL (Low-Density Lipoprotein): Main contributor; primary atherogenic particle
  • VLDL (Very Low-Density Lipoprotein): Triglyceride-rich particles that also carry cholesterol; estimated as triglycerides ÷ 5
  • IDL (Intermediate-Density Lipoprotein): Remnants of VLDL metabolism; highly atherogenic
  • Lp(a) (Lipoprotein(a)): LDL-like particle with additional apolipoprotein(a); very atherogenic and thrombogenic
  • Chylomicron remnants: Remnants of dietary fat absorption; atherogenic when present in fasting state

Why is Non-HDL Cholesterol Important?

Non-HDL cholesterol is increasingly recognized as an important cardiovascular risk marker and treatment target:

  • Captures all atherogenic particles: LDL alone doesn't account for VLDL, IDL, and Lp(a), which also contribute to atherosclerosis
  • Better predictor when triglycerides elevated: Patients with high triglycerides have more VLDL and remnants; non-HDL captures this additional risk
  • No fasting required: Unlike calculated LDL, non-HDL is valid on non-fasting samples
  • Valid when triglycerides >400 mg/dL: Friedewald equation fails above this level, but non-HDL remains accurate
  • Strong predictor of cardiovascular events: Studies show non-HDL predicts heart attack and stroke as well as or better than LDL alone

Non-HDL vs. LDL Cholesterol

Swipe to see more
Feature LDL Cholesterol Non-HDL Cholesterol
What it measures Cholesterol in LDL particles only Cholesterol in all atherogenic particles (LDL + VLDL + IDL + Lp(a))
Fasting required Yes (for calculated LDL) No
Valid when TG >400 No (calculated LDL invalid) Yes
Treatment priority Primary target Secondary target
Goal Based on risk category Typically LDL goal + 30 mg/dL
Best for Standard lipid assessment High TG, non-fasting samples, metabolic syndrome, diabetes

When to Use Non-HDL Cholesterol

Non-HDL cholesterol is particularly useful in these situations:

  • Triglycerides ≥200 mg/dL: Indicates significant VLDL and remnants not captured by LDL alone
  • Triglycerides ≥400 mg/dL: Calculated LDL invalid; use non-HDL or direct LDL
  • Non-fasting lipid panel: Non-HDL changes minimally with food; LDL calculation requires fasting
  • Metabolic syndrome: These patients have atherogenic dyslipidemia (high TG, low HDL, small dense LDL); non-HDL better captures their risk
  • Diabetes: Diabetic dyslipidemia characterized by triglyceride-rich particles; non-HDL superior risk marker
  • Chronic kidney disease: Altered lipoprotein metabolism; non-HDL may be better risk predictor
Normal Ranges

Non-HDL cholesterol is classified similarly to LDL cholesterol, with cutpoints 30 mg/dL higher than LDL thresholds.

Swipe to see more
Category Non-HDL Cholesterol Equivalent LDL Category
Desirable <130 mg/dL Optimal LDL (<100 mg/dL)
Above Desirable 130-159 mg/dL Near optimal LDL (100-129 mg/dL)
Borderline High 160-189 mg/dL Borderline high LDL (130-159 mg/dL)
High 190-219 mg/dL High LDL (160-189 mg/dL)
Very High ≥220 mg/dL Very high LDL (≥190 mg/dL)

Non-HDL Cholesterol Goals Based on Risk

The general rule: Non-HDL goal = LDL goal + 30 mg/dL

Swipe to see more
Risk Category LDL Goal Non-HDL Goal
Very High Risk
(Established ASCVD, recent ACS, diabetes + ASCVD)		 <70 mg/dL <100 mg/dL
High Risk
(CHD equivalent, 10-year risk >20%)		 <100 mg/dL <130 mg/dL
Moderate Risk
(2+ risk factors, 10-year risk 10-20%)		 <130 mg/dL <160 mg/dL
Low Risk
(0-1 risk factor)		 <160 mg/dL <190 mg/dL
2018 ACC/AHA Guidelines: Current guidelines focus primarily on statin intensity and LDL reduction percentage. However, when triglycerides are elevated (≥200 mg/dL), consider using non-HDL as secondary target. If non-HDL remains elevated despite statin therapy, consider adding ezetimibe or fibrate.
Clinical Significance

When Non-HDL is Elevated

Elevated non-HDL cholesterol indicates excess atherogenic lipoproteins. The same conditions that elevate LDL also elevate non-HDL, but conditions that increase triglyceride-rich lipoproteins cause disproportionate non-HDL elevation.

Conditions With Disproportionately High Non-HDL:

  • Metabolic syndrome: Insulin resistance increases VLDL production; non-HDL may be high even with borderline LDL
  • Type 2 diabetes: Diabetic dyslipidemia characterized by high triglycerides and small dense LDL; non-HDL captures total atherogenic burden
  • Hypertriglyceridemia: Elevated VLDL directly increases non-HDL; significant when triglycerides >200 mg/dL
  • Familial combined hyperlipidemia: Elevated LDL AND VLDL; non-HDL markedly elevated
  • Familial dysbetalipoproteinemia (Type III): Accumulation of VLDL and chylomicron remnants; very high non-HDL relative to LDL
  • Chronic kidney disease: Altered lipoprotein metabolism with increased remnant particles
  • Nephrotic syndrome: Massive increase in VLDL and LDL production

Discordance Between LDL and Non-HDL

Sometimes LDL and non-HDL tell different stories. This discordance is clinically important:

High Non-HDL with Normal LDL (Non-HDL > LDL + 30 mg/dL):

  • Interpretation: Significant burden of triglyceride-rich lipoproteins (VLDL, remnants)
  • Common in: Metabolic syndrome, diabetes, high carbohydrate diet, obesity
  • Implications: Higher cardiovascular risk than LDL alone suggests; LDL underestimates risk
  • Management: Consider non-HDL as primary target; lifestyle modifications (weight loss, low-carb diet, exercise); consider fibrate if non-HDL remains elevated on statin

Low Non-HDL with High LDL (Non-HDL < LDL + 30 mg/dL):

  • Interpretation: Very low triglycerides/VLDL; most non-HDL is LDL
  • Common in: Familial hypercholesterolemia, very low-fat diets, statin therapy
  • Implications: LDL accurately represents atherogenic burden
  • Management: Focus on LDL lowering
Example of Discordance:

Patient A: Total Chol 240, LDL 160, HDL 50, TG 150
Non-HDL = 240 - 50 = 190 mg/dL (expected 160 + 30 = 190, concordant)

Patient B: Total Chol 240, LDL 120, HDL 40, TG 400
Non-HDL = 240 - 40 = 200 mg/dL (expected 120 + 30 = 150, DISCORDANT - high TG)
Patient B has higher cardiovascular risk than LDL suggests due to VLDL burden.

Non-HDL in Special Populations

Diabetes Mellitus:

  • Non-HDL may be better cardiovascular risk predictor than LDL in diabetics
  • Diabetic dyslipidemia (high TG, low HDL, small dense LDL) means significant VLDL and remnant burden
  • Consider non-HDL as primary target if triglycerides persistently >200 mg/dL

Chronic Kidney Disease:

  • CKD alters lipoprotein composition; increased triglyceride-rich lipoproteins
  • Non-HDL may better predict cardiovascular events than LDL in CKD patients
  • Traditional LDL targets may underestimate risk

Children and Adolescents:

  • Non-HDL cutpoints for children: Acceptable <120 mg/dL, Borderline 120-144 mg/dL, High ≥145 mg/dL
  • Useful for familial hyperlipidemia screening when fasting difficult to obtain
  • Can be measured on non-fasting samples, improving pediatric screening compliance
Interpretation Guidelines

When to Use Non-HDL as Primary vs. Secondary Target

Use Non-HDL as SECONDARY Target (Most Common):

  • Triglycerides <200 mg/dL
  • Standard lipid panel assessment
  • Goal: Achieve LDL goal first, then ensure non-HDL is within 30 mg/dL of LDL goal

Use Non-HDL as PRIMARY or CO-PRIMARY Target:

  • Triglycerides ≥200 mg/dL persistently
  • Triglycerides ≥400 mg/dL (calculated LDL invalid)
  • Metabolic syndrome with atherogenic dyslipidemia
  • Diabetes with elevated triglycerides
  • Non-fasting lipid panel
  • Chronic kidney disease

Treatment Approach When Non-HDL is Elevated

Step 1: Optimize LDL with Statin

  • Start or intensify statin therapy to achieve LDL goal
  • Statins reduce both LDL and non-HDL (typically 30-50% reduction in both)

Step 2: Lifestyle Modifications for Triglycerides

  • Weight loss if overweight/obese (5-10% body weight)
  • Reduce refined carbohydrates and added sugars
  • Limit/eliminate alcohol
  • Regular aerobic exercise (150 min/week)
  • Improve glycemic control if diabetic
  • Increase omega-3 fatty acids (fatty fish 2-3x/week)

Step 3: Consider Additional Therapy if Non-HDL Remains Above Goal

  • Ezetimibe: If LDL still elevated; reduces LDL 15-20% and non-HDL proportionally
  • Fibrate (fenofibrate): If triglycerides ≥200 mg/dL despite statin; reduces TG 30-50%, increases HDL, modestly affects LDL
  • Omega-3 fatty acids (prescription): High-dose EPA (Vascepa) or EPA+DHA; reduces TG 20-50%; Vascepa shown to reduce cardiovascular events
  • PCSK9 inhibitor: If very high risk and non-HDL remains elevated despite max therapy; expensive

Interpreting Lipid Panel with Non-HDL

Systematic approach to lipid interpretation incorporating non-HDL:

Step-by-Step Interpretation:
  1. Calculate non-HDL: Total Chol - HDL
  2. Check LDL: Is it calculated or direct? Valid if TG <400 mg/dL
  3. Assess triglycerides: <150 normal, 150-199 borderline, ≥200 high
  4. Compare non-HDL to LDL: Should be ~30 mg/dL higher
    • If non-HDL ≈ LDL + 30: Concordant, normal VLDL
    • If non-HDL > LDL + 40-50: High VLDL/remnants (check TG)
    • If non-HDL < LDL + 20: Very low VLDL (low TG)
  5. Determine primary target: LDL in most cases, non-HDL if TG ≥200 or TG ≥400
  6. Assess both goals: LDL goal AND non-HDL goal based on risk category

Clinical Examples

Clinical Pearl
Example 1 - LDL at goal, Non-HDL not:
Patient with diabetes on atorvastatin 40 mg
Total Chol 185, LDL 95, HDL 35, TG 275
Non-HDL = 185 - 35 = 150 mg/dL

Interpretation: LDL at goal (<100), but non-HDL above goal (<130) due to high TG and VLDL. Atherogenic burden higher than LDL suggests.
Management: Lifestyle modifications for TG; consider adding fenofibrate or omega-3 to address elevated non-HDL and cardiovascular risk from remnant particles.
Clinical Pearl
Example 2 - High TG invalidates calculated LDL:
Patient with poorly controlled diabetes
Total Chol 280, HDL 30, TG 520
Calculated LDL = 280 - 30 - (520÷5) = 280 - 30 - 104 = 146 mg/dL (INVALID - TG >400)
Non-HDL = 280 - 30 = 250 mg/dL

Interpretation: Cannot trust calculated LDL. Use non-HDL as primary target (very high at 250 mg/dL). Triglycerides also dangerously elevated (pancreatitis risk approaching).
Management: Immediate glucose control, very low-fat diet, eliminate alcohol, start fibrate + omega-3, recheck in 1-2 weeks. Goal: TG <500 urgently, then focus on non-HDL <130.
Interfering Factors

Factors That Increase Non-HDL Cholesterol

Anything that increases atherogenic lipoproteins (LDL, VLDL, remnants) will increase non-HDL:

  • Dietary: High saturated fat (raises LDL), high refined carbohydrates (raises VLDL), trans fats (raise LDL, lower HDL)
  • Lifestyle: Obesity, sedentary behavior, smoking, excessive alcohol
  • Medical conditions: Hypothyroidism, diabetes, metabolic syndrome, nephrotic syndrome, CKD, cholestasis
  • Medications: Thiazides, beta-blockers, corticosteroids, estrogens (oral), protease inhibitors, immunosuppressants
  • Genetic: Familial hypercholesterolemia, familial combined hyperlipidemia, familial dysbetalipoproteinemia

Factors That Decrease Non-HDL Cholesterol

  • Medications: Statins (30-50% reduction), ezetimibe (15-20%), fibrates (variable, 10-30%), PCSK9 inhibitors (50-60%), omega-3 fatty acids (variable based on TG)
  • Lifestyle: Weight loss, regular exercise, healthy diet (high fiber, plant sterols, omega-3)
  • Medical conditions: Hyperthyroidism, malabsorption, severe liver disease

Analytical Considerations

  • No fasting required: Non-HDL changes minimally (<10 mg/dL) with meals; valid on non-fasting samples
  • Simple calculation: Total Chol - HDL; calculation errors rare but verify math
  • Depends on accuracy of Total Chol and HDL: If either is inaccurate, non-HDL will be inaccurate
  • Biological variation: Similar to total cholesterol (±8-10% day-to-day)
  • Acute illness: Both total cholesterol and HDL decrease during acute illness, so non-HDL also decreases; wait 6-8 weeks after acute event
Clinical Pearls
"Non-HDL = Total Chol - HDL" (Simple!): No complex calculations or fasting requirements. Simply subtract HDL from total cholesterol. This captures all atherogenic cholesterol particles (LDL + VLDL + IDL + Lp(a)) in one number.
Clinical Pearl
Non-HDL goal = LDL goal + 30 mg/dL: Easy rule to remember. If LDL goal is 100 mg/dL, non-HDL goal is 130 mg/dL. If LDL goal is 70 mg/dL (very high risk), non-HDL goal is 100 mg/dL. The 30 mg/dL accounts for normal VLDL cholesterol.
Clinical Pearl
No fasting required for non-HDL: Major advantage over calculated LDL. Total cholesterol and HDL change minimally with meals (<5-10 mg/dL), so non-HDL is valid on non-fasting samples. Great for patient convenience and pediatric screening.
Clinical Pearl
Use non-HDL when triglycerides ≥400 mg/dL: Friedewald equation becomes invalid at this level. Instead of ordering expensive direct LDL, use non-HDL as treatment target. Just as effective and immediately available from standard lipid panel.
Non-HDL better than LDL in metabolic syndrome: Patients with metabolic syndrome have high triglycerides, low HDL, and small dense LDL - the "atherogenic dyslipidemia" pattern. Non-HDL captures the increased VLDL and remnant particles that contribute to their high cardiovascular risk. LDL alone underestimates their risk.
Clinical Pearl
Check if non-HDL is concordant with LDL: Normally, non-HDL should be ~30 mg/dL above LDL. If non-HDL is >40-50 mg/dL above LDL, suspect high triglycerides and VLDL burden. This discordance suggests higher cardiovascular risk and need to address triglycerides.
Clinical Pearl
Non-HDL incorporates remnant lipoproteins: VLDL remnants (IDL) and chylomicron remnants are highly atherogenic but not captured by standard LDL measurement. Non-HDL includes these remnants, providing more complete picture of atherogenic burden, especially in diabetes and hypertriglyceridemia.
Don't forget to treat high non-HDL: If LDL is at goal but non-HDL remains elevated (typically due to high triglycerides), patient still has increased cardiovascular risk. Address triglycerides with lifestyle modifications (weight loss, low-carb diet, exercise) and consider fibrate or omega-3 if TG ≥200 mg/dL persistently.
Clinical Pearl
Non-HDL predicts cardiovascular events as well as LDL: Multiple studies show non-HDL cholesterol predicts myocardial infarction and stroke as well as or better than LDL alone. Some studies suggest it's superior, especially in patients with diabetes, metabolic syndrome, or high triglycerides.
Useful for children and non-fasting screening: Pediatric lipid screening challenging due to fasting requirements. Non-HDL can be obtained on non-fasting sample, improving screening compliance. Cutpoints for children: <120 acceptable, 120-144 borderline, ≥145 high.
Clinical Pearl
Non-HDL captures Lp(a): Lipoprotein(a) is an LDL-like particle with additional apolipoprotein(a). It's highly atherogenic and thrombogenic. Standard LDL measurement doesn't distinguish Lp(a) from LDL, but non-HDL captures both, providing better risk assessment in patients with elevated Lp(a).
Clinical Pearl
Statins reduce non-HDL proportionally to LDL: If statin reduces LDL by 50%, it typically reduces non-HDL by 40-50% as well. This makes sense since statins primarily work by reducing LDL, which is the major component of non-HDL. However, statins also modestly reduce VLDL.
Consider non-HDL in CKD: Chronic kidney disease alters lipoprotein metabolism, increasing triglyceride-rich lipoproteins and remnants. Non-HDL may be a better cardiovascular risk predictor than LDL in CKD patients. Guidelines increasingly recognize this in advanced CKD.
References
  1. Kratz, A., Ferraro, M., Sluss, P. M., & Lewandrowski, K. B. (2004). Laboratory reference values. New England Journal of Medicine, 351, 1548-1564.
  2. Lee, M. (Ed.). (2009). Basic skills in interpreting laboratory data. Ashp.
  3. Farinde, A. (2021). Lab values, normal adult: Laboratory reference ranges in healthy adults. Medscape. https://emedicine.medscape.com/article/2172316-overview?form=fpf
  4. Nickson, C. (n.d.). Critical Care Compendium. Life in the Fast Lane • LITFL. https://litfl.com/ccc-critical-care-compendium/
  5. Farkas, Josh MD. (2015). Table of Contents - EMCrit Project. EMCrit Project. https://emcrit.org/ibcc/toc/
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