For decades, high levels of HDL cholesterol—often called the “good cholesterol”—have been seen as a sign of a healthy heart. It’s one of the most common things I hear in my clinic: “My HDL is really high, so I must be protected, right?”

But what if that’s not the whole story?

Emerging research is now challenging this long-held belief. In this post, I’ll explain what HDL really does, why high levels might not always be protective, and what you should be focusing on instead to truly understand your heart disease risk.

What Is HDL and Why Is It Called the “Good” Cholesterol?

Your body produces two main types of cholesterol carriers: LDL (low-density lipoprotein) and HDL (high-density lipoprotein). LDL has traditionally been labeled the “bad” cholesterol because it delivers cholesterol from the liver to tissues throughout the body, including artery walls—contributing to plaque buildup and atherosclerosis.

HDL, on the other hand, does the opposite. It transports excess cholesterol from the body back to the liver where it can be excreted. This process, called reverse cholesterol transport, is one of the main reasons HDL earned its “good” reputation. In simple terms, HDL acts like a cleanup crew, helping to remove excess cholesterol from places it shouldn’t be.

But Here’s Where the Myth Begins…

Early research showed that people with higher HDL levels tended to have lower risk of heart disease. So naturally, the assumption became: the higher your HDL, the better.

But newer research is poking holes in this idea. A landmark 2018 study examined data from over 400,000 people. The surprising result? People with very high HDL levels actually had an increased risk of death—particularly men. It wasn’t just that high HDL didn’t help—it appeared to potentially make things worse.

Why Aren’t High HDL Levels Always Helpful?

One reason may have to do with how HDL functions, not just how much of it you have.

While standard lipid panels measure the quantity of HDL, they don’t tell us anything about its functionality. And that matters. To be protective, HDL must be able to interact with LDL particles and remove cholesterol effectively—this is the core of reverse cholesterol transport.

Some people may have lots of HDL in their blood, but if that HDL is dysfunctional, it may not be doing its job. In fact, accumulating large amounts of poorly functioning HDL could be harmful, which is what some researchers believe may be happening in people with very high HDL levels.

Why the Number Alone Isn’t Enough

Doctors often review lipid panels and breathe a sigh of relief when they see a high HDL number—especially if LDL is slightly elevated. But current science suggests that high HDL does not offset the risk of high LDL.

A study published in JAMA Cardiology found that people with both high LDL and high HDL still had a significantly increased risk of cardiovascular events. In other words, you can’t rely on high HDL to “cancel out” high LDL.

So What Should You Focus On?

We still want to avoid low HDL levels. If you’re a woman and your HDL is under 40, or a man with HDL under 50, your risk of cardiovascular disease increases. But once HDL surpasses 60–80 mg/dL, there is no clear added benefit—and potentially added risk.

Instead of focusing solely on HDL, look at your broader cardiovascular picture:

• LDL particle number and ApoB levels – These are more accurate markers than total LDL
• Inflammatory markers – Chronic inflammation can drive plaque buildup even with “normal” cholesterol
• Blood sugar and insulin levels – Metabolic health plays a major role in cardiovascular risk
• Blood pressure – High blood pressure is a leading cause of heart disease

We Need a More Complete Picture

Cardiovascular risk is complex. Looking at one number—like HDL—won’t give you the whole story. That’s why in my clinic, we use a more comprehensive panel of heart health markers to assess risk accurately and personalize prevention plans.

If you’re interested in learning about the specific blood tests we use to evaluate cardiovascular risk, I’ve created a downloadable guide that breaks them down in detail—along with optimal reference ranges, not just the standard ones.

👉 Click here to download the Heart Health Blood Test Guide

The Take Home Message

While HDL is still important, it’s time to move beyond the myth that “higher is always better.” Instead, we need to focus on the functionality of cholesterol, the presence of inflammation, and a full spectrum of metabolic and cardiovascular markers to get a real picture of your heart health.

If this article helped you better understand your bloodwork or sparked questions about your heart health, please share it with a friend or leave a comment. We’re here to help you take control of your health with clarity and confidence.

Dr. Kevin Passero is a functional medicine doctor with over 20 years of clinical experience helping people prevent and reverse heart disease through personalized lifestyle medicine, advanced testing, and targeted supplements.