THE LIPID PANEL What are we missing? Robert St. Amant, MD, FAAFP Diplomate, 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?