CAR039 Comprehensive Lipid Profile Testing in the Evaluation of ...
CAR039 Comprehensive Lipid Profile Testing in the Evaluation of ...
CAR039 Comprehensive Lipid Profile Testing in the Evaluation of ...
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is well known that CAD alone is <strong>the</strong> largest killer <strong>of</strong> American men and women, amount<strong>in</strong>g to more<br />
than 500,000 deaths per year. The highest <strong>in</strong>cidence <strong>of</strong> new CAD events is <strong>in</strong> persons >65 years <strong>of</strong> age<br />
and 85% <strong>of</strong> all deaths attributable to CAD occur <strong>in</strong> this population. Unfortunately, up to 1/3 <strong>of</strong> <strong>in</strong>itial<br />
presentation <strong>of</strong> CAD is sudden death. This statistic underscores <strong>the</strong> importance <strong>of</strong> appropriate<br />
cholesterol test<strong>in</strong>g and management, s<strong>in</strong>ce cholesterol blood level predicts CAD risk.<br />
The National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP III) guidel<strong>in</strong>es,<br />
released <strong>in</strong> 2001, focus on multiple risk factors and use <strong>the</strong> Fram<strong>in</strong>gham risk calculation to identify<br />
certa<strong>in</strong> patients for more <strong>in</strong>tense treatment. The ATP III guidel<strong>in</strong>es are endorsed by <strong>the</strong> American<br />
College <strong>of</strong> Cardiology (ACC) and American Heart Association (AHA).<br />
By strict ATP III def<strong>in</strong>ition, risk factors <strong>in</strong>clude:<br />
1. Family history (primary male relative with CAD before age 55, female relative before age 65),<br />
2. Hypertension (blood pressure >140/90),<br />
3. Low HDL (45).<br />
In general, low cardiac risk is described as no risk or one risk factor. Moderate cardiac risk is def<strong>in</strong>ed<br />
as two risk factors and a 10-year Fram<strong>in</strong>gham risk <strong>of</strong> less than 10%. Moderate high risk is def<strong>in</strong>ed as<br />
two or more risk factors and a 10-year Fram<strong>in</strong>gham risk <strong>of</strong> 10%-20%. High risk <strong>in</strong>dividuals have<br />
exist<strong>in</strong>g CAD (previous history <strong>of</strong> MI, stable or unstable ang<strong>in</strong>a, or revascularization with coronary<br />
artery bypass graft<strong>in</strong>g or percutaneous coronary angioplasty), or a CAD risk equivalent (e.g., diabetes<br />
mellitus, abdom<strong>in</strong>al aortic aneurysm, PVD, significant coronary artery disease, a 10-year Fram<strong>in</strong>gham<br />
risk that exceeds 20%).<br />
In July 2004, <strong>the</strong> NCEP updated some elements <strong>of</strong> <strong>the</strong> ATP III guidel<strong>in</strong>es based on review <strong>of</strong> 5<br />
additional cl<strong>in</strong>ical trials. In this update, very high risk patients (recent heart attack, or those who have<br />
cardiovascular disease comb<strong>in</strong>ed with diabetes, cont<strong>in</strong>ued smok<strong>in</strong>g, PVD, or metabolic syndrome) had<br />
an optional goal LDL less than 70 mg/dL. The National Heart Lung and Blood Institute (NHLBI)<br />
anticipates <strong>the</strong> release <strong>of</strong> ATP IV <strong>in</strong> <strong>the</strong> Spr<strong>in</strong>g <strong>of</strong> 2012.<br />
CLINICAL EVIDENCE<br />
I. BASIC LIPOPROTEIN PROFILE<br />
A basic lipoprote<strong>in</strong> pr<strong>of</strong>ile typically <strong>in</strong>cludes total cholesterol, HDL, triglycerides, and calculated LDL.<br />
In some cl<strong>in</strong>ical situations (e.g. presence <strong>of</strong> chylomicrons, elevated triglycerides >400 mg/dl), <strong>in</strong>direct<br />
LDL calculation may not be considered accurate (i.e. underestimated) and direct LDL calculations may<br />
be considered more appropriate.<br />
A. LDL. The ATP III guidel<strong>in</strong>es identify elevated LDL cholesterol as <strong>the</strong> primary target <strong>of</strong> <strong>the</strong>rapy<br />
and establish goals for LDL cholesterol that depend on a patient’s risk status. The ATP III guidel<strong>in</strong>es<br />
do not def<strong>in</strong>e <strong>the</strong> total cholesterol: HDL ratio as a specified target <strong>of</strong> <strong>the</strong>rapy; LDL rema<strong>in</strong>s <strong>the</strong> primary<br />
lipid lower<strong>in</strong>g target. The data on LDL predict<strong>in</strong>g CVD <strong>in</strong> randomized controlled trials (RCT) is<br />
<strong>Comprehensive</strong> <strong>Lipid</strong> <strong>Pr<strong>of</strong>ile</strong> <strong>Test<strong>in</strong>g</strong> <strong>in</strong> <strong>the</strong> <strong>Evaluation</strong> <strong>of</strong> Cardiovascular Disease Page 5 <strong>of</strong> 14