The Lipid Panel-Robert St. Amant, MD, FAAFP

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?
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