The genetic basis of familial combined hyperlipidemia (FCHL) has eluded investigators for 20 years, despite the apparent segregation of FCHL as an autosomal dominant disorder affecting 1% to 2% of individuals. Etiologic heterogeneity and additive effects of traits controlled by other genetic loci have been suggested. Two traits have been implicated in FCHL. The first is the predominance of a small, dense low-density lipoprotein (LDL), LDL subclass phenotype B, which segregates as a mendelian trait. The second is a mendelian locus with large effects on apolipoprotein (apo) B levels that is defined by complex segregation analysis (predicted apoB level genotype). This study shows that these factors F amilial combined hyperlipidemia (FCHL) is characterized by variable expression of hypercholesterolemia and hypertriglyceridemia in a given family, with either or both present in affected individuals.1 FCHL is associated with an excess risk of coronary artery disease (CAD) and was first reported by Goldstein et al 1 in 1973 in pedigrees ascertained through men who were survivors of myocardial infarction; over 10% of those probands were considered to have FCHL. One half to one third of familial premature CAD 2 and at least 10% of all premature CAD 1 -3 are ascribed to FCHL. This disorder is estimated to affect 1% to 2% of those in the populations studied and may be responsible for 5% of myocardial infarctions.1 While the inheritance of FCHL was originally described as consistent with an autosomal dominant disorder with full penetrance by the end of the third decade, 1 formal segregation analysis, adjusting for ascertainment, has not been reported. 4 Thus, the mode of inheritance remains uncertain.Efforts to refine the phenotype of FCHL have led to the observation that elevated levels of apolipoprotein Received May 4, 1994; revision accepted July 19, 1994. O 1994 American Heart Association, Inc.appear to be separate genetic effects, both of which aid in the prediction of FCHL in four large pedigrees. The results suggest that FCHL may be best predicted by a threshold model in which apoB level genotype and LDL subclass phenotype each act to increase the risk of FCHL. Heterogeneity in the transmission of apoB levels among families is suggested, supporting the etiologic heterogeneity of FCHL. These results emphasize the advantages inherent in the study of large pedigrees when disease heterogeneity is suspected.