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


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” 5 th 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”