CV Health: Three Ways to ‘kNOw’ Kathleen O’Neil-Smith, MD Malden, MA

Learning Objectives: Know Your Number ‘No’ Inflammation LDL-Particle # VS. LDL-Cholesterol as a determinant of risk and treatment ‘No’ Inflammation hs-CRP and JUPITER LpPLA2 is a marker of vascular inflammation Know degree of Insulin Resistance Lipid Metabolism in insulin resistance Relationship between inflammation and insulin resistance

Learning Objectives:

Coronary Heart Disease in the United States CHD is the single largest killer of men and women Each year 1.1 million people experience an MI 12 million have history of MI and/or angina 53.3 million adults have elevated LDL-C and warrant intervention By age 60, every 5th man and 17th woman develops CHD 1999 estimated direct and indirect costs of heart disease are $99.8 billion © Dr. Mary James and GSDL 2003

Heart Disease = Leading Cause of Death, Stroke = 2nd/3rd Leading Cause of Death Total Leading Causes of Death in the US Leading Causes of Death for American Women 315,000 82,000 71,000 65,000 41,000 50,000 100,000 150,000 200,000 250,000 300,000 350,000 Heart Disease Stroke Lung Cancer COPD Breast Cancer National Center for Health Statistics 2006. National Heart, Lung and Blood Institute, 2006 5

Sub-fractionation improves detection of people at cardiovascular risk These 30 patients would not have been identified as being at increased CardioVascular risk. Superko,HR Am J Cardiol 2001;88:260-64 © Dr. Mary James and GSDL 2003

>84 % of CAD >70 % of CAD Lipid Markers ~55 % of CAD Traditional Risk Factors Lipid Markers ~55 % of CAD Cardiovascular Profile Inflammatory Risk Markers >70 % of CAD Advanced Cardiovascular Profile Advanced Lipid Profile w/ fractionation Risk Markers of Inflammation Insulin Resistance >84 % of CAD © Dr. Mary James and GSDL 2003

Current guidelines for lipid management LDL Cholesterol: The Primary Target of Therapy JAMA, May 16, 2001 © Dr. Mary James and GSDL 2003

Limitations of LDL in Predicting CHD Framingham Heart Study - 26 year follow-up 50% of persons who develop CAD are missed with the routine lipid panel 80% of MI patient population have similar cholesterol levels as those who did not have an MI1 Elevated LDL-cholesterol is only one lipid abnormality associated with CHD2 As little as 25% of premature CHD is attributable to elevated LDL-C values In Framingham, 50% of patients with normal routine lipid panels still develop CAD LDL-cholesterol levels fail to differentiate populations of individuals with and without CHD. As seen in the Framingham Heart Study, 26 year follow-up data reveals that LDL-cholesterol levels were the same in 80 percent of patients who experienced a myocardial infarction (MI) versus those who did not experience an event. This limitation is more acute in patients with premature CHD. Due to the presence of non-LDL lipoprotein abnormalities, only some of which are associated with LDL-cholesterol elevations, as few as 25 percent of premature CHD patients have LDL-cholesterol elevations over 130 mg/dl. 1Castelli W, Atherosclerosis 1996; 124: S1-S9 2Genest J Jr, et al. J Am Coll Cardiol 1992;19:792-802 © Dr. Mary James and GSDL 2003

Standard Lipid Profile LDL HDL © Dr. Mary James and GSDL 2003

Patients with smaller LDL size have greater CHD risk at any given level of LDL-C. Lower risk Higher risk Cholesterol Balance 130 mg/dL But I want to introduce another aspect of the characteristics of people with small, dense LDL. At any given level of LDL cholesterol, if you have smaller LDL particles, by definition you have more of them. These are containers for cholesterol. The smaller the container, the less cholesterol it carries. So this relationship always holds. And so the question needs to be asked, and it was introduced in the previous talk: Is the greater risk associated with small, dense LDL actually caused by the size of LDL or is LDL size simply a marker for the fact that these folks have more LDL particles and it’s the greater number of LDL particles that’s responsible for the higher risk. So that’s really the key point where there is disagreement. Large LDL (Pattern A) Small LDL (Pattern B)

Patients with greater LDL-P have greater CHD risk at any given level of LDL-C. Lower risk Higher risk Cholesterol Balance 130 mg/dL But I want to introduce another aspect of the characteristics of people with small, dense LDL. At any given level of LDL cholesterol, if you have smaller LDL particles, by definition you have more of them. These are containers for cholesterol. The smaller the container, the less cholesterol it carries. So this relationship always holds. And so the question needs to be asked, and it was introduced in the previous talk: Is the greater risk associated with small, dense LDL actually caused by the size of LDL or is LDL size simply a marker for the fact that these folks have more LDL particles and it’s the greater number of LDL particles that’s responsible for the higher risk. So that’s really the key point where there is disagreement. Large LDL (Pattern A) Small LDL (Pattern B)

At The Same LDL-C Level, Number of LDL Particles Varies Up to 70% More Particles Cholesterol Balance 100 mg/dL Large LDL Small LDL Two patients with 100 mg/dL LDL-cholesterol. The patient on the left has fewer particles because more cholesterol is being carried in each particle, and they are cholesterol enriched. The patient on the right has more particles because they are cholesterol depleted

Carotid Atherosclerosis in MESA* LDL-C <100 mg/dL (n=1,425) Carotid IMT (microns) Q1 <1055 Q2 1055-1285 Q3 1285-1545 Q4 >1545 n=32 Concordant with LDL-C n=153 n=352 n=888 Why do I say that? This slide shows the adjusted IMT values of these different groups of individuals, all with low LDL-C - the green concordant group and the yellow and red discordant groups. These are increasing quartiles of LDL particle number. The concordant group (green) with the lowest LDL-P has the lowest carotid IMT. When LDL particle number is higher (Q2) the atherosclerosis is higher. When LDL particle number is much higher (Q3 and Q4), the atherosclerosis is much higher. Note that these are analyses adjusted not only for non-lipid variables, but also for HDL-C and TG. So despite the fact you might expect the cardiovascular disease risk, or the atherosclerosis in this case, to be greater among those with lower LDL size, lower HDL-C and higher triglycerides, these data show that at least a portion of the reason for the higher atherosclerosis in these low LDL-C individuals is their increased LDL particle number. LDL Particle Number

Carotid Atherosclerosis in MESA* LDL-C = 100-130 mg/dL (n=1,362) n=143 Concordant with LDL-C n=371 Carotid IMT (microns) n=499 n=349 So let’s look at what the carotid atherosclerosis of these groups tells us. Here’s the concordant group in yellow. When LDL-P is lower (green), completely independent of everything else, atherosclerosis is lower. When LDL-P is higher (red), atherosclerosis is clearly higher – and there is a strong, almost linear, graded relationship with atherosclerosis, independent of other lipid and non-lipid risk factors. To me, this data is very informative and has important implications for the management of LDL-related CVD risk. Q1 <1055 Q2 1055-1285 Q3 1285-1545 Q4 >1545 LDL Particle Number

Weight of Evidence LDL-C levels have long been the guideline directed focus and goal for the treatment of atherosclerosis in order to reduce risk of CVD. There is ongoing evidence that shows many patients who have reached target LDL-C levels have a high residual risk for CVD, due to an increased concentration of atherogenic low density lipoproteins (LDL-P). The next part of the presentation will review the data from some of these studies.

CHD Event Associations of LDL-P versus LDL-C Framingham Offspring Study (n=3,066) Event-Free Survival Concordant Discordant Years of Follow-up Cromwell WC et al. J Clin Lipidology 2007;1(6):583-592.

CHD Event Associations of LDL-P versus LDL-C Framingham Offspring Study (n=3,066) Better survival Lower risk Worse survival Higher risk Low LDL-C Low LDL-P (n=1,249) High LDL-C High LDL-P (n=1,251) Event-Free Survival Concordant Discordant Years of Follow-up Cromwell WC et al. J Clin Lipidology 2007;1(6):583-592.

CHD Event Associations of LDL-P versus LDL-C Framingham Offspring Study (n=3,066) Years of Follow-up Event-Free Survival Low LDL-C High LDL-P (n=282) High LDL-C Low LDL-P (n=284) Better survival Lower risk Worse survival Higher risk (n=1,249) (n=1,251) Concordant Discordant Cromwell WC et al. J Clin Lipidology 2007;1(6):583-592.

ADA and ACC Consensus Statement In Patients at Risk Summary A more accurate way to capture the risk posed by LDL may be to measure the number of LDL particles directly using nuclear magnetic resonance (NMR) “Many cross-sectional and prospective studies show that LDL particle number is a better discriminator of risk than is LDL cholesterol.” Measurements of apoB or LDL particle number by NMR more closely quantitate the atherogenic lipoprotein load. Brunzell JD, Davidson M, Furberg CD et al. Diabetes Care 2008;31:811-822 Thomas Dayspring MD

ADA and ACC Consensus Statement In Patients at Risk Summary ApoB and LDL particle number also appear to be more discriminating measures of the adequacy of LDL lowering therapy than are LDL cholesterol or non-HDL cholesterol.” ApoB and LDL particle concentration also appear to be more closely associated with obesity, diabetes, insulin resistance, and other markers of CMR than LDL cholesterol or non-HDL cholesterol.” Brunzell JD, Davidson M, Furberg CD et al. Diabetes Care 2008;31:811-822 Thomas Dayspring MD

LDL Lowering Drugs Reduce LDL-P Current lipid modifying therapies exert unique effects on lipoprotein particle number and size. In terms of low-density lipoprotein (LDL), “statins” (HMG Co A reductase inhibitors) afford the greatest reduction in LDL particle concentration. The magnitude of particle reduction is greatest for high potency statins and least for low potency statins. Niacin primarily increases LDL particle size and secondarily reduces particle concentration. Likewise, fibrates, through their triglyceride lowering properties, primarily increase LDL particle size and have the ability to reduce LDL particle number. High-density lipoprotein (HDL) levels are increased most significantly in response to niacin therapy, followed by fibrates and statins. The particle population enhanced to the greatest extent on all pharmacologic therapies is the cardio-protective large subclass. Recent statin trials also demonstrate that the group achieving the greatest HDL particle benefit is the group with low HDL-cholesterol levels (< 35 mg/dL) at baseline.

Treatment Statins lower total LDL but don’t change particle size Niacin, fenofibrate, aspirin, exercise, and weight loss increase LDL particle size

Treatments that Change LDL-C & LDL-P Differentially Cholesterol per particle decreases with: statins statin + ezetimibe estrogen replacement therapy anti-retrovirals (some) low fat, high carb diet LDL-C More Cholesterol per particle increases with: fibrates niacin glitazones omega 3 FAs exercise low carb diet LDL-P More

Inflammation Systemic & Vascular

The Causes of Inflammation Diet Sugar Trans and saturated fats Polyunsaturated omega 6 oils (except GLA) Insufficient fruits and vegetables Stress Lack of exercise Toxins (metals, petrochemicals) Infections – esp. dental Obesity/ Insulin Resistance

Inflammation Story of Pier’s friend - tried all - stapling but no change till gluten - and inflammation

Hepatic Source of Inflammatory Markers: hs-CRP and Fibrinogen Rader. N Engl J Med 2000;343:1179.

hs-CRP = Risk Factor for CVD Kuller MRFIT1996 CHD death Ridker PHS 1997 MI Ridker PHS1997 Stroke Tracy CHS/RHPP1997 CHD Ridker PHS1998,2001 PAD Ridker WHS 1998,2000,2002 CVD Koenig MONICA1999 CHD Roivainen HELSINKI 2000 CHD Mendall CAERPHILLY 2000 CHD Danesh BRITAIN 2000 CHD Gussekloo LEIDEN 2001 Fatal Stroke Lowe SPEEDWELL 2001 CHD Packard WOSCOPS 2001 CV Events Ridker AFCAPS 2001 CV Events Rost FHS 2001 Stroke Pradhan WHI 2002 MI, CVD death Albert PHS 2002 Sudden Death 0 1.0 2.0 3.0 4.0 5.0 6.0 Relative Risk (upper versus lower quartile) Ridker PM. Circulation 2003;107:363-369

C-Reactive Protein Marker of inflammation, infection and injury Aspirin’s reduction of MI risk appears to be related to CRP levels CRP activates complement which injures the inner layer of blood vessels  constriction of vessels, arrhythmia Strong predictor of the risk of future MI JUPITER Study – November, 2008 49% decrease in CDA end-points 20% decrease in ‘all cause’ mortality! 40% of participants had insulin resistance. . . © Dr. Mary James and GSDL 2003

Lp-PLA2 Lipoprotein-associated phospholipase A2 (Lp-PLA2, also known as PLAC) is an enzyme produced by intimal-based macrophages and foam cells in the early stages of atherosclerotic plaque formation. Lp-PLA2 activity promotes inflammation and plaque instability. Levels of Lp-PLA2 reflect atherosclerosis disease activity as opposed to plaque burden. This is significant because most heart attacks and sudden coronary deaths are attributable to plaque rupture at sites of only moderate stenosis. The PLAC Test for Lp-PLA2 is the only FDA-cleared blood test that helps identify hidden risk for both heart attack and stroke. Early detection and more aggressive treatment can help prevent these cardiovascular events. The PLAC Test measures Lp-PLA2 (lipoprotein-associated phospholipase A2), a vascular-specific inflammatory enzyme implicated in the formation of rupture-prone plaque. It is plaque rupture and thrombosis, not stenosis, that cause the majority of cardiac events. 50% of cardiovascular events strike in patients with unremarkable lipid levels, highlighting the prevalence of hidden cardiovascular risk. A substantial body of evidence including over 50 studies and abstracts in peer-reviewed journals and conferences support Lp-PLA2 as a cardiovascular risk marker that provides new information, over and above traditional risk factors. Consistent with ATP III guidelines, the PLAC Test should be used as an adjunct to traditional risk factors assessment to identify which moderate or high risk patients, as initially assessed by traditional risk factors, may actually be at higher risk. An elevated PLAC Test may indicate a need for more aggressive therapy, including treatment to lower LDL-C goals. Lipid lowering therapies, including statins, are proven to reduce cardiovascular events regardless of baseline LDL-C levels. The PLAC Test is the only blood test cleared by the FDA to aid in assessing risk for both coronary heart disease and ischemic stroke associated with atherosclerosis. Since LDL has proven not to be a reliable predictor of stroke, the PLAC Test addresses this unmet clinical need. The PLAC Test is covered by Medicare at $47.43 and by a growing number of private payers. However, patients may be required to pay out-of-pocket – a small investment in their future health.

Gorelick PB, et al. Am J Card Suppl 2008.

Additive Effect of CRP and Lp-PLA2 in Coronary Risk Prediction: MONICA CRP ≤ 3 mg/L Lp-PLA2 < 290.8 ng/mL N=447 CRP > 3 mg/L N=176 Lp-PLA2 ≥ 290.8 ng/mL N=203 N=108 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 6.0 Ref. Hazard Ratio (95% CI) Unadjusted Adjusted for age Multivariable DM, smoking adjustment* Koenig et al. (AHA 2003)

Summary and Conclusions Lp-PLA2 was the strongest predictor/biomarker of coronary events, and was independent of traditional and emerging risk factors, including CRP in hyperlipidemic individuals (WOSCOPS) In particular, in individuals with low LDL-C (<130 mg/dL), levels of Lp-PLA2 were independently associated with incident CHD in multivariable analysis including CRP (ARIC) Lp-PLA2 was predictive of coronary events in a population-based sample of initially healthy middle-aged men with moderately elevated total cholesterol levels during long-term FU of 14 years (MONICA cohort)

Inflammation and Insulin Resistance Cause and Effect

NCEP/ ATP III National Cholesterol Education Program Adult Treatment Panel III Standard guidelines used by MDs Focus on identifying early risk & prevention New criteria for ‘CardioMetabolic Syndrome’ Increased waist/hip ratio Hypertension > 130/85 Fasting Glucose >100 Elevated Triglycerides > 150 Decreased HDL < 40 [m], < 50 [f] © Dr. Mary James and GSDL 2003

Obesity Trends* Among U.S. Adults BRFSS, 1986 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

Obesity Trends* Among U.S. Adults BRFSS, 1996 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% > 15%

Obesity Trends* Among U.S. Adults BRFSS, 2006 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) We have never had an epidemic like this that we have been able to track so thoroughly and see. As I told you, this is conservative. About 60 million adults, or 30 percent of the adult population, are now obese, which represents a doubling of the rate since 1980. No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Antecedents, Triggers and Mediators Genetic propensity Inflammation Chronic Stress High Glycemic Diet Visceral Adiposity Lack of Exercise Smoking Insulin Resistance Elevated fasting and postprandial Insulin & glucose blood levels FM approach must look at ATM’s

Rates of CardioMetabolic Syndrome BMI < 25 BMI 25-30 BMI >30 MEN 30% 51% 71% WOMEN 21% 43% 65% TOTAL 26% 46% 68%

Continuum of Insulin Resistance Wellness Illness Insulin Sensitive Insulin Resistance Insulin Resistance Diabetes Compensated Non-compensated Health No Symptoms Symptoms/Pathology

Increased coagulation Heart Disease Diabetes Mellitus Insulin Resistance LDL oxidation Plaque formation Atherosclerosis Increased coagulation Abdominal Obesity Dyslipidemia Hyperglycemia Hypertension (This collection of factors creates the “perfect storm” in terms of disease risk.) Throughout the course of this presentation, we’ll explore how the intimate relationships between these factors– IR, obesity, and inflammation—creates, in essence, the ‘perfect storm’ for CVD and DM. Inflammation Oxidative Stress (free radicals)

Changes in Lipid Fractions Insulin Resistance – Changes in Lipid Fractions Lipoprotein Subclass Particle Numbers: Large VLDL Medium VLDL Small VLDL IDL Large LDL Small LDL Large HDL Med HDL Small HDL VLDL Particle Number (VLDL-P) VLDL Size LDL Particle Number (LDL-P) LDL Size HDL Particle Number (HDL-P) HDL Size

Independent Risk Factors Lipid Markers Independent Risk Factors 71 yo Arab man on statins C3040315 Insulin Resistance Score by Lipid Fractionation

Independent Risk Factors Lipid Markers Independent Risk Factors 49yo male on very, very low fat diet C2240267 Insulin Resistance Score by Lipid Fractionation

Independent Risk Factors Lipid Markers Independent Risk Factors 32yo male with +FHx of MI, comes for evaluation of CHOL. MD wants LDL-C <100. C2170252 Insulin Resistance Score by Lipid Fractionation

The Clinical Approach We know the problem and the magnitude and we see pts daily so my answer is simple: Obesity is of major concern, it increases cardiometabolic risks We know insulin resistance is a major cause of obesity (at least 70%) Clinical trials have proven insulin sensitivity can be improved through lifestyle modification and 5-10% reduction in body weight improves insulin sensitivity, lipid profiles, endothelial function, reduces thrombosis and inflammatory markers There is a 3-fold increase in the odds that a patient will attempt weight loss if it is recommended by a trusted health care professional

Conclusions Although the causes of obesity are many; insulin resistance and the resulting hyperinsulinemia is a major cause. Emphasis should be on early identification of those patients who are insulin resistant for aggressive targeted intervention. Diet, lifestyle and targeted nutritional/botanical supplementation (medical nutrition) can positively effect insulin sensitivity and lead to improved outcomes. By looking for, identifying and treating early insulin resistance the current trends of obesity can be not only treated but reversed as well.

How to use Advanced CV Risk Assessment Screening Guidelines from NCEP: All adults > 20 years of age should be screened with a fasting lipid panel every 5 years. Advanced CV Risk Assessment optimizes case identification in high risk patients Advanced CV Risk Assessment is able to monitor treatment response …optimizing lipid fractionation and independent factors in high risk patients. © Dr. Mary James and GSDL 2003

Who is HIGH RISK? All men >40 years old. All women >50 years old. Anyone with a family history of heart disease, MI, or stroke Anyone who is over-weight/ obese. Anyone with hypertension, diabetes, or elevated traditional lipid markers. Smokers THIS COMPRISES many patients – but it is not for everybody! © Dr. Mary James and GSDL 2003

Learning Objectives: Know Your Number ‘No’ Inflammation LDL-Particle # VS. LDL-Cholesterol as a determinant of risk and treatment ‘No’ Inflammation hs-CRP and JUPITER Know your degree of Insulin Resistance Lipid Metabolism in insulin resistance Relationship between inflammation and insulin resistance