Most patients do not show any of the conventional risk factors for cardiovascular disease.1 In a recent CMAJ article, Jean-Pierre Després and colleagues emphasized the need to look beyond traditional risk factors, such as the plasma level of low-density lipoprotein cholesterol, as they might not provide enough predictive power for accurate risk stratification.2 The authors focused on a cluster of factors characterizing the “metabolic syndrome” and especially on the novel measurement of the ratio of total cholesterol to high-density lipoprotein cholesterol.
In a recent study in which we evaluated the cardiovascular risk profile of elderly male patients, we confirmed the limited significance of traditional risk factors, such as total cholesterol or low-density lipoprotein cholesterol levels, and we observed a striking relationship between cardiovascular disease and the ratio of total cholesterol to high-density lipoprotein cholesterol.3 However, we also noted that the high levels of lipoprotein(a) and homocysteine in these patients may have contributed to the development of cardiovascular complications in our clinical setting. These 2 factors, along with an elevated ratio of total cholesterol to high-density lipoprotein cholesterol, were highly predictive for cardiovascular disease. Therefore we agree with Després and colleagues on the need to look beyond low-density lipoprotein cholesterol and we further suggest that lipoprotein(a) and homocysteine measurements be included when assessing cardiovascular risk.