the lipid panel what are we missing? robert st. amant, md, faafp diplomate, american board of...

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?