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High HDL Cholesterol (Hyperalphalipoproteinemia) Clinical Presentation

  • Author: Vibhuti N Singh, MD, MPH, FACC, FSCAI; Chief Editor: George T Griffing, MD  more...
Updated: Jul 14, 2016


Hyperalphalipoproteinemia (HALP) has no specific symptoms. It is usually identified through the routine assessment of a lipid profile. Another member of a patient's family may have been found to have elevated high-density lipoprotein (HDL) cholesterol levels. Aside from its cardioprotective role, HALP is occasionally associated with the following symptoms and signs:

  • Juvenile corneal opacification
  • Multiple symmetric lipomatosis[22]
  • History related to secondary causes
    • History of alcohol abuse
    • Treatment with medications such as oral estrogens, statins, niacin (ie, nicotinic acid), phenytoin, or fibrates (eg, bezafibrate, clofibrate, fenofibrate, gemfibrozil)[5, 7]
    • History of vigorous, sustained aerobic exercise (eg, long-distance running)


Patients with asymptomatic hyperalphalipoproteinemia (HALP) do not present with any significant physical findings. Rare patients may exhibit the following:

  • Juvenile corneal opacification - This is described in patients with marked HALP.
  • Multiple systemic lipomatosis - In rare cases, the development of multiple lipomas has been reported.


Causes of hyperalphalipoproteinemia (HALP) may be primary or acquired (secondary). Primary factors can include familial syndromes of elevated high-density lipoprotein (HDL) cholesterol levels, which in some cases may be associated with a decreased risk for coronary artery disease .

  • Primary causes
    • Familial HALP - Familial HALP includes CETP deficiency, familial hepatic lipase deficiency, and primary HALP. A selective up-regulation of apo A-I production is one metabolic cause of familial HALP and leads to high plasma concentrations of HDL cholesterol, apo A-I, and lipoprotein A-I. It possibly may also result in protection from atherosclerotic coronary heart disease (CHD).[23, 24] Familial HALP can involve premature corneal opacity, reduced hepatic lipase activity, and reduced uptake of HDL by lymphocytes.
    • Primary HALP - This is a term used for familial elevated HDL cholesterol levels that are not due to CETP deficiency. Epidemiologic studies have suggested that this syndrome is associated with a decreased risk for coronary artery disease and with increased longevity.
    • CETP deficiency - This asymptomatic, hereditary syndrome is caused by low CETP levels. Decreased CETP activity slows the transport of cholesteryl esters from HDL to apo B–containing lipoproteins. The condition is frequently observed in Japanese Americans. Clinical features include marked elevations of plasma HDL cholesterol in homozygotes (usually >100 mg/dL) and probably lower rates of CHD. In heterozygotes, the HDL levels are only moderately elevated. CETP deficiency has not yet been demonstrated to be associated with a decreased risk for atherosclerotic cardiovascular disease, and some experts do not consider this condition protective against cardiovascular disease.[25]
    • LCAT overexpression - Rarely, HALP has been reported to be due to LCAT overexpression. The activity of LCAT is increased in blood plasma and is associated with high levels of HDL. Reduction in the fractional catabolic rate of HDL is considered to be the predominant mechanism by which LCAT overexpression modulates HDL concentrations. Such patients may have reduced risk of developing CHD.
    • Up-regulation of apo A-I production - Selective up-regulation of apo A-I production is another cause of familial HALP. Affected individuals have elevated HDL cholesterol and apo A-I levels. Additionally, many patients have a reduced risk of atherosclerotic CHD.
  • Secondary causes[5, 7]
    • Vigorous and sustained aerobic exercise (eg, long-distance running)
    • Regular, substantial alcohol consumption
    • Treatment with oral estrogens, particularly if not opposed by progestins
    • Treatment with statins
    • Treatment with nicotinic acid (niacin) at doses greater than 1 g/d
    • Treatment with phenytoin
    • Primary biliary cirrhosis
    • Treatment with fibrates (eg, bezafibrate, clofibrate, fenofibrate, gemfibrozil)
Contributor Information and Disclosures

Vibhuti N Singh, MD, MPH, FACC, FSCAI Clinical Assistant Professor, Division of Cardiology, University of South Florida College of Medicine; Director, Cardiology Division and Cardiac Catheterization Lab, Chair, Department of Medicine, Bayfront Medical Center, Bayfront Cardiovascular Associates; President, Suncoast Cardiovascular Research

Vibhuti N Singh, MD, MPH, FACC, FSCAI is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Heart Association, American Medical Association, Florida Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Don S Schalch, MD Professor Emeritus, Department of Internal Medicine, Division of Endocrinology, University of Wisconsin Hospitals and Clinics

Don S Schalch, MD is a member of the following medical societies: American Diabetes Association, American Federation for Medical Research, Central Society for Clinical and Translational Research, Endocrine Society

Disclosure: Nothing to disclose.

Chief Editor

George T Griffing, MD Professor Emeritus of Medicine, St Louis University School of Medicine

George T Griffing, MD is a member of the following medical societies: American Association for the Advancement of Science, International Society for Clinical Densitometry, Southern Society for Clinical Investigation, American College of Medical Practice Executives, American Association for Physician Leadership, American College of Physicians, American Diabetes Association, American Federation for Medical Research, American Heart Association, Central Society for Clinical and Translational Research, Endocrine Society

Disclosure: Nothing to disclose.

Additional Contributors

Ghassem Pourmotabbed, MD, MD 

Ghassem Pourmotabbed, MD, MD is a member of the following medical societies: American Diabetes Association, American Federation for Medical Research, Endocrine Society

Disclosure: Nothing to disclose.

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