1. 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

2. Conflict of Interest Statement:  Speakers Bureau for the following companies: Abbott Laboratories CardioDx Kowa/Lilly Berkeley HeartLab  Clinical Investigator: CardioDx

3. 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.

4. The Lipid Panel  Total Cholesterol  Triglycerides  HDLc  LDLc …….What’s missing?

5. Cholesterol  Cell structure  Sex hormones  Bile acids  Vitamin D

6. Total Cholesterol  Structure  Sources  NCEP goal?

7. Triglycerides  Structure  Sources  Purpose  NCEP target

8. HDL cholesterol  Structure  Sources  Purpose  NCEP target

9. LDL cholesterol  Structure  Sources  Purpose  Primary NCEP ATPIII goal

10. 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

11. NCEP ATPIII LDLc Goals:  CHD/CHD risk equivalents  Moderate CHD risk  Low CHD risk  Non-HDLc goal  TG primary goal

12. 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

13. Lipoproteins  Insolubility  Lipid trafficking vehicles  ApoA and ApoB  Interheart Study  ApoB/ApoA

14. ApoB Lipoproteins  Size  Composition  Atherogenic  Discordance  LDLc, LDLp, MIs

15. ApoA Lipoproteins  Protective  HDL cholesterol  Functions  Quantity vs Quality  HDLc vs HDLp  Protein Cargo

16. Atherosclerosis  Complex process  Progressive  Inflammatory  Endothelial dysfunction  Atheroma burden  Plaque rupture

17. Risk Factors  Lifestyles  Non-modifiable  Modifiable  Insulin resistance

18. Insulin Resistance  Definition  Diagnosis  Prevalence  70% of MIs  Treatment

19. Metabolic Syndrome  5 Criteria  3/5 = diagnosis  1/3 adults  Screening  CAD & DM risks

20. Looking Beyond the Lipid Panel  Using Selected Biomarkers  Not for low risk patients  Diligent risk evaluation  Residual risk on statin therapy

21. Advanced Cholesterol Testing  Beyond the lipid panel  Not for everyone  Intermediate and high risk patients  Affordable  Part of “What’s Missing?”

22. Lp(a)  LDL particle with an apo(a) protein  Very atherogenic  Disrupts process of fibrinolysis  MI/stroke risk  CV events with normal lipids

23. Lp-PLA2  Enzyme on LDLp  Rapid plaque formation  Prone to rupture  MI / stroke risk  Treat BP/meds

24. SLCO1B1 Genotype  Gene variation for OATP  Increased level statin drug  Myalgia risk  Statin “intolerance”

25. Thank You! Questions?