Case #360: Basic lipid panel underestimates LDL, misclassifies risk

Fifty-eight year old “Zachary” was referred to our office in early 2012 to establish care and undergo a physical. He reported having occasional heartburn for years and recently had a basic lipid panel (BLP) through his work.

The patient’s initial checkup showed:

• Height = 72 inches
• Weight = 225 pounds
• Waist = < 40
• BMI = 30
• BP = 125/75
• HR = 73

The patient’s BLP and labs showed:

• LDLc = 89
• TC = 146
• TG = 120
• HDLc = 33
• Glucose = 92

Zachary has a strong family history of heart disease, reporting that multiple men on his father’s side have had heart attacks (including his father). Zachary is a non-smoker and non-drinker who exercises regularly.

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It’s May and Stroke Awareness Month. Stroke is the fourth leading cause of death in the U.S. and a leading cause of adult disability.

With stroke awareness in the news and on our patients’ minds, adding a valuable risk assessment to our patient’s lab work may create a greater sense of urgency to be compliant with treatment recommendations when they understand there is active disease present, and not just risk of disease.

The PLAC Test, developed by diaDexus, Inc. and offered with the VAP Lipid Panel from Atherotech, determines levels of Lp-PLA₂ (lipoprotein-associated phospholipase A2) in the blood. Individuals with elevated levels of Lp-PLA₂ have been shown to have an increased risk of ischemic stroke and coronary heart disease — especially when combined with high blood pressure.

More than 30 studies have evaluated the risk of CAD and CVD when Lp-PLA₂ is elevated. The optimal value appears to be under 200, although some studies have suggested even lower values.

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Case #356: Pheromones, Macrophages and the Rumblings of Mount St. Helens

I recently saw “Leah,” a 67-year-old female. She had a history of hypertension, dyslipidemia and impaired fasting glucose. Her blood pressure and cholesterol issues were fairly well-controlled on ramipril 10 mg and simvastatin 20 mg.

At just over five feet in height, Leah weighed 141 lbs, had a BMI 26.6 and blood pressure of 136/82. A non-smoker and non-drinker, Leah walks three miles per day, takes fish oil and vitamin D supplements and daily ASA 81 mg.

Leah was in fairly good health overall with good lipids and recently lost 40 lbs through lifestyle management counseling and support. Her Lp(a), however, was very high at 28, and her LpPLA₂ at 214.22 (high) along with GlycoMark at 15 (low, which is bad) were of concern. Also of some concern is her family history: her mom suffered a stroke, and her father died during bypass surgery at age 65.

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Recent guidelines from the American Association of Clinical Endocrinologists identify the biomarker Lp-PLA₂ as a strong and independent predictor of cardiovascular disease events and stroke. The AACE’s medical guidelines for clinical practice were published in the March/April 2012 issue of Endocrine Practice.

With more than 50 cardiovascular and metabolic tests available as direct-order, Atherotech provides clinicians with the company’s patented VAP Lipid Panel, the PLAC Test for Lp-PLA₂ and other tests for cardiovascular risk biomarkers.

The PLAC Test, developed by diaDexus, Inc., is the first blood test for determining the risk for ischemic stroke associated with atherosclerosis. The test determines levels of Lp-PLA₂ (lipoprotein-associated phospholipase A₂) in the blood. Individuals with elevated levels of Lp-PLA₂ have been shown to have an increased risk of ischemic stroke and coronary heart disease.

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Inflammation plays a major role in atherogenisis, adversely impacts lipid metabolism and transport, and leads to the development of atherosclerotic plaque. Lipoprotein associated phospholipase A2 (LpPLA₂) is emerging as one of the most promising serum markers of inflammation.

In a recent journal article* that I collaborated on with Kenneth J. Colley, M.D., and Robert L. Wolfert, M.D., we reviewed more than two dozen peer-reviewed and published articles that demonstrate the utility of LpPLA₂ in more accurate CVD risk assessment.

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