Date post: | 25-Dec-2015 |
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THE LIPID PANEL
What are we missing?
Robert St. Amant, MD, FAAFPDiplomate, American Board of Clinical Lipidology
Baton Rouge General Medical Director, Lipid Center
Womack Heart Center
Conflict of Interest Statement: Speakers Bureau for the following companies:
• Abbott Laboratories
• CardioDx
• Kowa/Lilly
• Berkeley HeartLab
Clinical Investigator:• CardioDx
Audience Objectives:
Have a better understanding of the standard lipid panel and cardiovascular disease risks.
Be able to discuss the relationship between cholesterol and lipoproteins and why patients with normal lipid panels have cardiovascular events.
Explore more advanced cholesterol, biomarker, and genetic tests available to enhance cardiovascular disease risk assessment.
The Lipid Panel
Total Cholesterol Triglycerides HDLc LDLc
…….What’s missing?
Cholesterol
Cell structure Sex hormones Bile acids Vitamin D
Total Cholesterol
Structure Sources NCEP goal?
Triglycerides
Structure Sources Purpose NCEP target
HDL cholesterol
Structure Sources Purpose NCEP target
LDL cholesterol
Structure Sources Purpose Primary NCEP ATPIII goal
Non-HDL Cholesterol
What??? “New” 5th lipid fraction ALL BAD cholesterol, not just LDLc. Atherogenic lipoprotein particles Residual risk Secondary NCEP goal: 30mg/dL above LDLc goal
NCEP ATPIII LDLc Goals:
CHD/CHD risk equivalents Moderate CHD risk Low CHD risk Non-HDLc goal TG primary goal
CVD Risk Factors
Smoking Age >/=45M, 55F HPT >/=140/90 Low HDL <40* Family Hx CAD Age <55M, <65F
* HDL >/= 60 is a negative risk factor
Lipoproteins
Insolubility Lipid trafficking vehicles ApoA and ApoB Interheart Study ApoB/ApoA
ApoB Lipoproteins
Size Composition Atherogenic Discordance LDLc, LDLp, MIs
ApoA Lipoproteins
Protective HDL cholesterol Functions Quantity vs Quality HDLc vs HDLp Protein Cargo
Atherosclerosis
Complex process Progressive Inflammatory Endothelial dysfunction Atheroma burden Plaque rupture
Risk Factors
Lifestyles Non-modifiable Modifiable Insulin resistance
Insulin Resistance
Definition Diagnosis Prevalence 70% of MIs Treatment
Metabolic Syndrome
5 Criteria 3/5 = diagnosis 1/3 adults Screening CAD & DM risks
Looking Beyond the Lipid Panel
Using Selected Biomarkers Not for low risk patients Diligent risk evaluation Residual risk on statin therapy
Advanced Cholesterol Testing
Beyond the lipid panel Not for everyone Intermediate and high risk patients Affordable Part of “What’s Missing?”
Lp(a)
LDL particle with an apo(a) protein Very atherogenic Disrupts process of fibrinolysis MI/stroke risk CV events with normal lipids
Lp-PLA2
Enzyme on LDLp Rapid plaque formation Prone to rupture MI / stroke risk Treat BP/meds
SLCO1B1 Genotype
Gene variation for OATP Increased level statin drug Myalgia risk Statin “intolerance”
Thank You!
Questions?