Background: The inverse association between HDL-cholesterol (HDL-C) levels and the risk of cardiovascular diseases is evident. Hypothesis: Our hypothesis was that higher levels of HDL-C predisposed patients with coronary artery disease (CAD) to chronic coronary syndromes (CCS) rather than acute coronary syndrome (ACS), which has not clearly been demonstrated yet. Aim: To determine, in an unselected population of patients treated with percutaneous coronary intervention (PCI), if HDL-C levels are independently higher in subjects presenting with CCS compared with those with ACS. Methods and Results: In this retrospective study, we identified 4215 patients who underwent PCI in the Cardio-FR database. A total of 2942 patients met the selection criteria and completed at least a 1-year follow-up: 1686 suffered an ACS whereas 1256 presented with CCS. We found that low HDL-C levels were significantly associated with ACS and high HDL-C levels with CCS. This was consistent across all BMI categories in both genders. In addition, higher HDL-C levels reduced the likelihood of CAD subjects developing ACS. Specifically, each mmol/L increase in HDL-C decreased the odds of ACS by 79%. Interestingly, the CCS group had more polymorbid subjects than the ACS group. At 2-year follow-up, no difference in patient-oriented composite endpoint was seen between high and low HDL-C groups. Conclusion: In an unselected population of coronary patients, HDL-C levels were consistently lower in individuals presenting with ACS compared with CCS, independently of BMI and gender. This finding strengthens the hypothesis that HDL-C plays a role in long-term protection against atherosclerotic plaque vulnerability. Considering HDL-C level still makes sense.
