An Isolated Total Cholesterol Level Is Inadequate

To the Editor.—  In her commentary on cholesterol screening, Ms Merz¹ discusses the need for lipoprotein analysis, in addition to total cholesterol measurements. As a military pathologist, I have been involved with autopsies on four middle-aged men who have died of acute myocardial infarction while exercising. None of these men has had a total cholesterol level greater than 6.21 mmol/L by the Lipid Research Clinics method,² although the two with high-density lipoprotein cholesterol (HDL-C) values both had cholesterol/HDL-C ratios greater than 4.00, including the one with a total cholesterol level greater than 5.17 mmol/L. Since most patients who die of cardiovascular disease at this medical center also do not have elevated total cholesterol levels, I began to question the reliability of isolated total cholesterol measurements.First, I looked at 1-month mortality in patients with cardiovascular disease who survived to admission and who had total cholesterol levels measured. Only