ORIGINAL ARTICLE

Lipid Profiles of Acute Coronary Syndrome Patients

Hospitalized in ICCU of Cipto Mangunkusumo Hospital
Daulat Manurung

ABSTRACT
Aim: to see which component of the triad lipid that has
more important role and frequently found in patients with
acute coronary syndrome, focusing on HDL cholesterol.
Methods: a lipid profile study has been conducted in
391 patients with acute coronary syndrome (ACS), who have
been hospitalized in ICCU of Cipto Mangunkusumo Hospital since January 1st, 2001 December 31st, 2005.
Results: there were 294 male patients (75.2%) and 97
female patients (24.8%), from 25-89 years age group, with
mean value 57.35 11.05. The mean value of total cholesterol level was 205.23 mg/dl 54.84. The LDL cholesterol
level was 136.16 mg/dl 47.29. The mean HDL cholesterol
level was 42.84 mg/dl 10.28, mean triglycerides level was
157.25 mg/dl 100.16. There were 82 patients (21%) with
high total cholesterol (> 240 mg/dl), 102 patients (26.1%)
with high and very high LDL cholesterol level (> 160 mg/dl),
152 (38.6%) patients with low HDL cholesterol level (< 40
mg/dl), consisted of 126 male patients or 42.9% of total male
patients, 26 female patients or 26.8% of total female patients.
The number of patients with high / very high triglycerides
level (> 200 mg/dl or 500 mg/dl) was 84 patients (21.5%).
The number of patients with optimal lipid level, total
cholesterol level < 200 mg/dl was 191 patients (48.8%); 82
patients (21%) had LDL cholesterol level < 100 mg/dl, 23
patients (5.9%) had HDL cholesterol level > 60 mg/dl, 226
patients (57.8%) had triglycerides level < 150 mg/dl. There
were 260 patients with atherogenic lipid profile (64%), 135
patients with borderline lipid profile (34.5%), and optimal
lipid profile was found only in 6 patients (1,5%). The mean
value of HDL cholesterol level in male patients was 41.75
mg/dl 9.9, while HDL cholesterol level in female patients
was 46.16 mg/dl 10.74. Principally, lipid profiles of all age
groups were evenly distributed. ACS patients with history of
family heart disease had a more atherogenic lipid profile
compared to lipid profile of patients with hypertension,
diabetes mellitus, and cigarette smoking.

Division of Cardiology, Department of Internal Medicine Faculty

of Medicine, University of Indonesia-dr. Cipto Mangunkusumo
Hospital, Jakarta

196

Conclusion: atherogenic lipid profile is more common

risk factor in ACS patients than in other non-lipid risk
factors. This study also demonstrated that the atherogenic
lipid is most commonly found in patient with low HDL
cholesterol level and it is least frequently found in patient
with optimal lipid profile.
Key words : lipid profile, acute coronary syndrome.
INTRODUCTION

Elevated blood cholesterol level is a main risk factor

of atherosclerosis process, which underlies the development of coronary heart disease, including acute
coronary syndrome. Total blood cholesterol consists of
Low Density Lipoprotein (LDL) cholesterol, which is
the largest component of total cholesterol, i.e. 60-70%
of total cholesterol.1 LDL cholesterol is very atherogenic
(a very atherogenic lipoprotein) and it should be
decreased and represents the major cause of CHD, it
should be decreased. The correlation between elevated
LDL cholesterol level and CHD development should be
observed as a multi step process, which starts from the
young age.2,3,4 Plaque rupture or erosion usually leads to
acute coronary syndrome (acute myocardial infarct,
unstable angina pectoris and sudden death caused by
coronary heart disease).5-8
The second cholesterol component is high density
lipoprotein (HDL) cholesterol. Normally, it is 20-30% of
total cholesterol. HDL cholesterol is one of important
lipoproteins and is very potential to prevent atherosclerosis by changing the biology of arterial wall lesion,
without being affected by LDL cholesterol level.9 HDL
cholesterol has two mechanisms causing changes in
biology of arterial wall lesion.
Correlation between blood triglyceride level and CHD
may be derived from various mechanisms such as,
triglycerides may which cause a more atherogenic LDL
cholesterol. It may cause higher clearance rate of HDL
cholesterol, which finally causes low HDL cholesterol
level. Triglycerides may cause endothelial dysfunction,

Vol 38 Number 4 October - December 2006

Lipid Profiles of Acute Coronary Syndrome Patients Hospitalized

and may stimulate macrophages migration into endothelium. It may also stimulate vascular endothelial to
promote thrombogenic mediator synthesis, for example:
Plasminogen Activator Inhibitor (PAI-1).10 NCEP /ATP
III regards < 150mg/dL as optimal level. 150 -189 mg/dl
as borderline level, 200 499 mg/dl as high level, and
> 500 mg/dl as very high level.1
In this study, we will see, which component of the
triad lipid that has more important role and frequently found
in patients with acute coronary syndrome, focusing on
HDL cholesterol.
METHODS

This study was a retrospective cross-sectional study

based on medical records of ACS patients in Cipto
Mangunkusumo Hospital ICCU from January 1st, 2001
to December 31st, 2005.
RESULTS

During the course of study (January 1st, 2001)

December 31st, 2005), there were 568 patients with acute
coronary syndrome (ACS) hospitalized in ICCU
(Intensive Coronary Care Unit) of Cipto Mangunkusumo
Hospital. There were 391 patients, i.e. 294 male (75.2%)
and 97 female (24.8%), who had complete lipid profile
records including total cholesterol, LDL cholesterol, HDL
cholesterol and triglycerides. The study also recorded
the non-lipid coronary risk factors such as diabetes
mellitus in 132 patients (33.8%), hypertension in 229
patients (58.6%), smoking in 205 patients (52.4%),
familial heart disease in 61 patients (15.6 %). The
subjects age was about 2589 years old with mean value
of 57.3511.05.
The mean value of total cholesterol level was 205.23
54.84, LDL cholesterol level was 136.1647.29 mg/dl,
HDL cholesterol level was 42.84 10.28 mg/dl, and
triglycerides level was 157.25100.16 mg/dl. (Table 1)
Table 1. Mean Value of Lipid Profile in ACS
Lipid Profile
Total cholesterol mg/dl
LDL cholesterol mg/dl
HDL cholesterol mg/dl
Triglycerides mg/dl

Mean (SD)
205.23 54.84
136.16 47.29
42.84 10.28
157.25 100.16

There were 82 patients (21%) with high total

cholesterol level (> 240 mg/dl), 191 patients (48.8%) with
total cholesterol less than 200 mg/dl and 118
patients (30.2%) with borderline cholesterol level between
200-239 mg/dl. (Table 2)

Table 2 . Distribution of Total Cholesterol Level in ACS

Based on NCEP/ATP III Criteria
Total Cholesterol
(mg/dl)

Number of Patient

Percentage
(%)

82
118
191
391

21.0
30.2
48.8
100.0

> 240 high

200-239 borderline
< 200 desired
Total

There were 41 patients (10.5%) with LDL

cholesterol level more than 190 mg/dl (very high level),
61 patients (15.6%) with LDL cholesterol level between
160-189 mg/dl (high level), 101 patients (25.8%) with
LDL cholesterol level between 130-159 mg/dl, 106
patients (27.1%) with LDL cholesterol level between
100-129 mg/dl, and 82 patients (21%) with LDL cholesterol level less than 100 mg/dl (optimal level). (Table 3)
Table 3 . Distribution of LDL Cholesterol Level in ACS
Based on NCEP/ATP III Criteria
LDL Cholesterol
(mg/dl)

Number of Patient

Percentage
(%)

41
61
101
106

10.5
15.6
25.8
27.1

82
391

21.0
100.0

> 190 very high

160-189 high
130-159 nearly high
100-129 beyond
optimal
< 100 optimal
Total

Patients with high HDL cholesterol level > 60 mg/dl

were 23 patients (5.9%) of all ACS patients, consisting
of 12 male patients (3.1%) and 11 female patients
(11.3%). (Table 4)
Table 4. Distribution of HDL Cholesterol Level in ACS
Based on NCEP/ATP III Criteria
HDL Cholesterol
(mg/dl)

Number
of Patient

Percentage
(%)

> 60 mg/dl high

40 59 mg/dl borderline
< 40 mg/ dl low
Total

23
216
152
391

5.9
55.5
38.6
100.0

There were 126 male patients (42.9 %) and 26

female patients (26.8%) among total number of 152
patients (38.6%) with low HDL cholesterol level, less
than 40 mg/dl. (Table 5)
While total HDL cholesterol level in male was 41.75
mg/dl 9.9, and the level in female was 46.16 mg/dl
10.74.
197

Daulat Manurung

Acta Med Indones-Indones J Intern Med

Table 5. Distribution of HDL Cholesterol Level

< 40 mg/dl in ACS

Table 8 . Distribution of Patients with Optimal Lipid

Level in ACS

Sex

Number
of Patient

Percentage
(%)

Lipid Category (mg/dl)

Number

Percentage
(%)

Male (294 subjects)

Female (97 subjects)
Total (391 subjects)

126
26
152

42.9
26.8
38.6

Total Cholesterol <200

LDL Cholesterol < 100
HDL Cholesterol > 60
Triglycerides < 150

191
82
23
226

48.8
21.0
5.9
57.8

There were 84 patients (21.5%) with high triglyceride

level > 200 mg/dl, 2 patients with very high triglyceride
level > 500 mg/dl (0.5%). There were also 226 patients
with triglyceride level of <150 mg/dl (57.8 %) and 81
patients with triglyceride level of 150199 mg/dl (20.7%).
(Table 6)
Table 6. Distribution of Triglyceride Level in ACS
Based on NCEP/ATP III Criteria
Triglycerides
(mg/dl)

Number of Patient

Percentage
(%)

< 150
150-199
200-499
> 500
Total

226
81
82
2
391

57.8
20.7
21.0
0.5
100.0

Furthermore, there were 82 patients (21%) with high

total cholesterol level more than 240 mg/dl, 102 patients
(26.1%) with high LDL cholesterol level more than
160mg/dl. There were 152 patients (38.6%) with low
HDL cholesterol level < 40 mg/dl and 84 patients (21.5%)
with high triglyceride level > 200 mg/dl. (Table 7)
Table 7. Distribution of Patients with Atherogenic Lipid
in ACS
Lipid Category (mg/dl)

Number

Percentage
(%)

Total Cholesterol > 240

LDL Cholesterol > 160
Low HDL Cholesterol < 40
Triglycerides > 200

82
102
152
84

21
26.1
38.6
21.5

In keeping with optimal lipid profile level, there were

191 patients (48.8%) with total cholesterol level < 200
mg/dl, 82 patients (21%) with LDL cholesterol level
< 100 mg/dl. There were also 23 patients (5.9%) with
high HDL cholesterol > 60 mg/dl and 226 patients (57.8%)
with triglyceride level < 150 mg/dl. (Table 8).
But according to the combination of atherogenic lipid
triad (High LDL level, low HDL level, and high
triglyceride level), there were 10 patients (2.6%) who
had complete atherogenic lipid profile.
198

If it calculated based on two combination of atherogenic lipid, there were 68 patients (17.4 %), while if it
calculated based on single atherogenic lipid, there were
172 patients (44%). No lipid atherogenic was found in
141 patients (36 %). Moreover, if the three lipid types
were optimal, only six patients were found (1.5 %). There
were 141 patients 6 patients 135 patients with
borderline lipid profile (34.5 %). (Table 9)
Table 9. Combination of Lipid Triad in ACS patients
Lipid Combination
3 atherogenic lipid
2 atherogenic lipid
1 atherogenic lipid
Borderline lipid
Optimal lipid

10
68
172
135
6

2.6
17.4
44.0
34.5
1.5

In keeping with percentage of two atherogenic lipid

combination, there were 32 patients with combination of
low HDL level and high triglyceride level (8.2 %). There
were 21 patients with combination of high triglyceride
level and high LDL level (5.4 %) and 15 patients with
combination of low HDL level and high LDL level
(3.8%). (Table 10)
Table 10. Combination of Two Atherogenic Lipid in 391
ACS Patients
Lipid Combination
Low HDL Cholesterol High
Triglycerides
High LDL Cholesterol, High
Triglycerides
High LDL Cholesterol, Low HDL
Cholesterol
Total

32

8.2

21

5.4

15

3.8

68

17.4

Lipid distribution based on Age Group may be seen

on table 11.
While lipid profile in patients with non-lipid risk
factor of coronary heart disease, hypertension, smoking,
diabetes mellitus and history of familial heart disease may
be seen in table 12, 13, 14, 15.

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Lipid Profiles of Acute Coronary Syndrome Patients Hospitalized

Table 11. Distribution of Lipid Profile Based on Age Group

Age.
Group

Num

Total
Chol

SD

LDL
Chol

SD

HDL
Chol

SD

Trig
Chol

SD

20-29
30-39
40-49
50-59
60-69
70-79
>=80

2
17
71
129
111
51
10

0.5
4.3
18.2
33
28.4
13.
2.6

124.5
206.41
209.00
208.99
200.78
201.18
213.90

14.85
40.32
56.24
51.64
56.68
54.63
82.83

68.0
135.65
140.47
137.81
135.81
127.47
147.20

15.56
35.00
46.33
42.93
50.68
49.24
71.82

35.50
44.00
41.32
42.45
42.34
46.43
45.50

9.19
9.60
9.64
10.16
10.17
11.16
11.98

127
149.41
185.70
171.08
134.57
141.22
129.70

74.95
63.65
99.55
135.28
61.35
62.70
60.13

Table 12. Lipid Profile in ACS Patients with Hypertension (N = 229; 58.8%)

Total Cholesterol
LDL Cholesterol
HDL Cholesterol
Triglycerides

Mean SD

Median

Minimum

Maximum

209.76 58.51
138.47 50.43
42.99 9.52
161.72 86.59

204
132
42
140

50
34
12
33

553
461
84
744

Table 13. Lipid Profile in ACS Patients with Smoking Habit (N = 205; 52.4%)

Total Cholesterol
LDL Cholesterol HDL
Cholesterol
Triglycerides

Mean SD

Median

Minimum

Maximum

202.62 52.68
135.24 44.82
41.62 9.52
157.31 86.78

203
131
41
139

50
34
19
30

382
292
76
744

Table 14. Lipid Profile in ACS Patients with Diabetes (N = 132; 33.7%)

Total Cholesterol
LDL Cholesterol
HDL Cholesterol
Triglycerides

Mean SD

Median

Minimum

Maximum

206.09 62.0
138.47 50.43
42.99 9.52
161.72 86.59

200
132
42
140

87
34
12
33

553
461
84
744

Table 15. Lipid Profile in ACS Patients With History of Familial Heart Disease

Total Cholesterol LDL

Cholesterol
HDL Cholesterol
Triglycerides

Mean SD

Median

Minimum

Maximum

216.92 49.25
142.21 43.26
41.02 9.07
177.89 117.65

223
146
41
157

114
57
17
33

340
274
62
744

DISCUSSION

The lipid profile including total cholesterol level, LDL

cholesterol level, HDL cholesterol level, and triglyceride
level obtained from other studies in western countries/
from literature have similar results to this study.11,12
A study of CHD population in Jakarta also has
similar result.13 (Table 16)
There is a correlation between low HDL cholesterol
level and other atherogenic factors. Most of individuals
with low HDL cholesterol level demonstrate a correlation

to high triglycerides and remnant lipoprotein levels

(quoted of reference 1). In addition, low HDL cholesterol level usually correlated to small dense LDL
particle.27 There is strong correlation between low HDL
cholesterol level, high LDL cholesterol level, and high
triglycerides level, which demonstrate the term of Lipid
Triad as mentioned before.
In this study, we may observe that among
atherogenic lipid, combinations, the combination of low
HDL cholesterol level and low triglycerides is the most
199

Daulat Manurung

Acta Med Indones-Indones J Intern Med

Table 16. Comparison of Lipid Profile in Present Study and Other Studies

Total Cholesterol
LDL Cholesterol
HDL Cholesterol
Triglycerides

Mean (SD)
11
(Nissen et al )

Mean (SD)
12
(Nissen et al )

Mean (SD)
13
(Sarwono )

Mean (SD)
(Present Study)

204 (41.2)
130.4 (34.3)
43.1(11.1)
152.2 (81.7)

232 34.2
150 26.9
426 10.7
197.1 105.6

198 47.0
111.4 31.5
44.5 7.3
150.8 101

202.22 54.84
136.16 47.29
42.84 10.20
157.25 100.16

common, including 32 patients (8.2%). While the

combination of high LDL cholesterol level and high
triglycerides level is on the second rank with 21 patients
(5.4%) and the least frequent combination is high LDL
cholesterol disorder and short of breath, which is found
in 15 patients or 3.8%. (Table 10)
It is also noted that among 391 ACS patients, there
are 250 patients (64%) who have atherogenic lipid, and
the most common is only in single atherogenic lipid found
in 172 patients (44%). About 68 patients (17.4%) have
combination of two atherogenic lipid, while optimal lipid
profile is only found in 6 patients (1.5%) of 391 patients.
In addition, lipid profile of borderline level is found in 135
patients (34.5%). (Table 9)
Among four non-lipid coronary risk factors, lipid
profile of ACS patients with familial history have a more
atherogenic lipid profile, which indicates higher LDL
cholesterol and triglycerides level compared to other
patients with smoking habit, hypertension and diabetes
mellitus.
The most common non-lipid coronary risk factors are
hypertension in 229 patients (58.8%), followed by
smoking in 205 patients (52.4%), diabetes in 132 patients
(33.7%), and the least common is history of familial heart
disease in 61 patients (15.1%).
In keeping with the distribution of atherogenic lipid
profile, low HDL cholesterol level is the most common
atherogenic lipid, which is found in 152 patients (38.6%),
while high LDL cholesterol level, high triglycerides level
and high total cholesterol level are relatively similar, which
are 26.1%, 21.5% and 21 % respectively (Table 7).
Furthermore, among 152 patients with low HDL
cholesterol, there are 126 male patients (42.9%) and 26
female patients (26.8%). This result is lower than in
Framingham study, which shows 57% male CHD
patients with HDL cholesterol level < 40 mg/dl, while
the CARE study indicates 40% female patients with acute
infarct have HDL cholesterol level of < 40mg/dL. But
from these data, it is clear that ACS patients with low
HDL level are more found in male group (42.9%) than
the female (26.8%). In contrast, high HDL cholesterol
level is more frequently found in female group (11.3%)
than male (3.1%) (table 4.5). The mean value of HDL
200

cholesterol level is lower in male group (41.75mg/dl 9.9)

compared to female (46.16mg/dL 10.74). These data
are similar to data found from previous studies.13, 15-17
In relation to optimal lipid profile, the most common
is optimal triglycerides level < 150 mg/dl, which is found
in 226 patients (57.8%), followed by total cholesterol level
< 200 in 191 patients (48.8%) and the least frequent is
HDL cholesterol, which is only found in 23 patients
(5.9%). (Table 8)
The most common lipid distribution is total
cholesterol level of < 200 in 191 patients (48.8%). LDL
cholesterol level between 100 -159 is found in 207
patients (52.9%), borderline HDL cholesterol level of
40-59 mg/dl is found in 216 patients (55.5%), triglycerides level of < 150 is found in 226 patients (57.8%). (Table
2, 3, 4, 6)
While the composition of lipid profile based on age
group is evenly distributed, although the age group of
40-49 years has higher triglycerides level compared to
other age groups, and the age group > 80 years has higher
total cholesterol and LDL level. Higher cholesterol level
is found in the age group of > 70 years and > 80 years
compared to other age groups. It is interesting that the
younger age group has a lower HDL cholesterol level,
lower total cholesterol level, lower LDL cholesterol level,
and also lower triglycerides level (isolated low HDL
cholesterol ?) (quoted of reference 1), but it only occurs
in 2 patients, therefore it is difficult to regard this as a
comparison. (Table 11)
CONCLUSION

The composition of lipid profile in this study is

relatively similar to other data in western countries.
Among 391 ACS patients, it is found that the most
common atherogenic lipid is low HDL cholesterol about
38.6%, while the number/percentage of other atherogenic
lipid is relatively similar. There are 64% atherogenic lipid
found as single atherogenic lipid, and there are only about
1.5% who have optimal lipid profile, and 34.5% who have
borderline lipid profile. It also demonstrates that mean
value of HDL cholesterol level is higher in female than
in male group. Combination of low HDL cholesterol and

Vol 38 Number 4 October - December 2006

Lipid Profiles of Acute Coronary Syndrome Patients Hospitalized

high triglycerides level is about 8.2%, high LDL cholesterol and high triglycerides level are about 5.4% and
combination of high LDL cholesterol level and low HDL
cholesterol level is about 3.8%. The most common
optimal lipid profile is triglycerides and total cholesterol
level, i.e. 57.8% and 48.8% respectively.
The most common non-lipid coronary risk factor is
hypertension (58.8%) and smoking (52.4%). The more
atherogenic lipid profile lipid is found in patients with
history of familial heart disease.
This study is a retrospective study, therefore it is not
known whether the patient already had any previous
therapy of hypolipidemic agents, and there is no record
about it. This obviously affects the cholesterol examination of hospitalized ACS patients. Other risk factors, such
as metabolic syndrome, are not recorded, but the major
coronary risk factors have been included in this study.
Since low HDL cholesterol is the largest component
of other atherogenic lipids, education about increasing
HDL cholesterol is important in order to provide primary
prevention by emphasizing the importance of total health
life changes

3.

ACKNOWLEDGEMENT

12.

I would like to thank dr. Taufik for his endeavor to

collect the medical data in this study and to Ms. Sri
Rahayu Kadarwati, SKM for her help in preparing this
manuscript.

4.

5.
6.

7.
8.

9.

10.
11.

13.

14.

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