1. A New Look at CHD Risk Factors
Total Cholesterol
LDL-Cholesterol
HDL-Cholesterol
Lipoprotein(a)
Homocysteine
Particle size/density
Lp subclasses
Triglycerides
Inflammatory factors
Oxidized-LDL (Ox-LDL)
Metabolic syndrome
Prothrombotic factors
Apolipoproteins
Glucose impairment
Subclinical atherosclerotic diseases
Diabetes mellitus
Life-habit risk factors

2. Measure LDL-C More Accurately
Friedewald Calculation:
l LDL = TC – (HDL + VLDL)
(TG/5 approximates VLDL)
Recommendation: Not valid with TG > 400 mg/dL
l LDL = Lp(a) + IDL + Remnant Lp + LDL
l Total Error = Bias + (1.96 x CVImprecision)
< 12% (ideal: + 4% & CV < 4%)
From: Clin Chem 41: (1995)

3. Accuracy of LDL-c Calculation Method
Triglycerides Percent Correct Percent
Mg/dL (Within + 10%) Incorrect
< % %
% %
% %
% %
> < 20% > 80%
From: Warnick GR et. al. Clin Chem 36:15-19 (1990)

4. Accuracy of LDL-c Calculation Method
Triglycerides Correct LDL-C Incorrect LDL-C
mg/dL (Within + 10%)
< % %
% %
% %
% %
From: Warnick GR et. al. Clin Chem 36:15-19 (1990)

5. Friedewald Misclassifies Risk Category When Triglycerides > 177 mg/dL
Estimating LDL-C is Unreliable
When triglycerides (TG) > 400 everyone knows the LDL may be 25% falsely low and you have to order a directly measured LDL. You may not realize that even at relatively modest elevations of TGs when TG > 200 the estimated, or Friedewald LDL is already 10% falsely low or more, at TG > 300 it may be 15%-20% falsely low. What’s more when TG < 100 Friedewald breaks down again and you get a falsely low LDL.
In this study by Marnieri of 225 patients whose LDL was measured with the preparative ultracentrifuge, it was found that the Friedewald equation would have put persons in the wrong LDL risk category as much as half the time – this occurred for patients with TG > 177 mg/dl (which is > 2.0 mmol/l).
Of course you’re supposed to fast for Friedewald else TG’s go up and the estimated LDL goes down. In my mind we systematically underestimate LDL with Friedewald mainly because so many patients do not really fast.
LDL Risk Category
Marniemi J et al. Clin Biochem 1995 June; 28:

6. When LDL-C Target is < 100 Friedewald Should Not Be Utilized
Directly Measured LDL Cholesterol
When LDL-C Target is < 100 Friedewald Should Not Be Utilized
The third and perhaps most important reason to move immediately to direct LDL measurement in all patients is that Friedewald never intended for us to use his equation on persons’ with low LDL values, I.e. LDL-C < 100 mg/dL. The Friedewald equation is 15% - 19% falsely low in persons whose directly measured LDL is under 100 mg/dL. We are in an era where all CAD patients should have LDL below 100 and it must be measured directly to be accurate.
The fact that VAP provides a direct LDL-C, reliable at values below 100, reliable in persons with high or low TGs, and reliable in non-fasting persons - is sufficient reason alone to replace the old lipid panel with the VAP. It’s just a Better Cholesterol Test. When you switch you will notice that your patient’s LDLs suddenly look higher because the Friedewald underestimates LDL.
*Scharnagl H et al. Clin Chem Lab Med May;39(5):

7. Evaluation of Four Homogeneous Direct LDL-C Methods
Study: LDL-C methods from Genzyme, Reference Diagnostics (RD), Roche, and Sigma were evaluated for precision, accuracy, and specificity for LDL in the presence of abnormal lipoproteins.
Results: Precision was < 2% CV for all methods; and correlation to the CDC reference method was r = ; total error was Genzyme = 12.6%, RD = 16.5%, Sigma = 38.3%, Roche = 41.6%.
Conclusion: The methods show nonspecificity toward abnormal lipoproteins, thus compromising accuracy. These direct methods are no better than the Friedewald LDL-C.
From: Miller, WG et.al. Clin Chem 48: (2002)

8. Review of LDL-C Methods
1. Ultracentrifugation:
Reference method, accuracy based
Time-consuming, tedious, technically difficult, costly
2. Electrophoresis:
Simultaneous separation of major lipoprotein fractions, can quantitate, visualize some unusual bands
Technically difficult to do; unless automated, it can be tedious and time consuming, can be costly + - + -

9. Review of LDL-C Methods (Cont.)
3. Third Generation Direct Methods: +
No pretreatment, full automation, improved analytical precision, fasting specimen not required, save on labor cost
Can have lack of LDL specificity; inaccuracy because of analytical interferences from TG, bilirubin, IDL-C, Lp-X, VLDL-C, Lp(a), apo E-rich HDL, and/or hemoglobin; can be costly
From: Nauck M et. al. Clin Chem 48: (2002) -

10. HDL-c Testing NCEP Laboratory Goals
Total Error = ≤ 13% (analytical bias +1.9% CV)
TE = Ideal: ≤ 5% and ≤ 4% CV
CDC Reference Method: 3 Stage Procedure
Ultracentrifuge = remove chylomicron + VLDL
Heparin MnCl2 ppt. = remove apoB lipoprotein
Abell-Kendall cholesterol assay on HDL
CRMLN Designated Comparison Method
Dextran Sulfate (50,000 DA) ppt.
Abell Kendall cholesterol assay on HDL

11. Homogenous HDL-c Methods
There are 4 types of homogeneous HDL-C methods: immunologic, PEG, synthetic polymer, enzymatic.
All can be automated & directly measure HDL.
Most have excellent precision (< 3% CV).
Many have CRMLN certification, suggesting that accuracy is possible with proper instrument, reagents, and calibrator.
Specificity and interferences: most are robust and can tolerate TG < 900 mg/dL, but biases can occur with atypical lipoprotein patterns.
From: Warnick et. al. Clin Chem 47: (2001)

12. Review of HDL-c Methods
1. Ultracentrifugation:
Comparison method for accuracy
Time-consuming, tedious, technically difficult, costly, can have interference from Lp(a) and others
2. Electrophoresis:
Simultaneous separation of major lipoprotein fractions, can quantitate, visualize some atypical bands
Technically difficult to do; unless automated, it can be tedious and time consuming, can be costly + - + -

13. Review of HDL-C Methods (Cont.)
3. Third Generation Direct Methods: +
No pretreatment, full automation, improved analytical precision (<3% CV), fasting specimen not required, save on labor cost (20% savings)
Can have lack of HDL specificity; inaccuracy because of analytical interferences from bilirubin, hemoglobin, high TG (chylomicrons and VLDL-c), Lp(a), apo E-rich HDL, and/or HDL variants (Apo A-IMilano)
From: Nauck M et. al. Clin Chem 48: (2002) -

14. New Approaches to Quantitative Lipoprotein Electrophoresis
Completely automated; better precision
Better gel/buffer system (high-resolution)
Precision control of temperature during electrophoresis
Densitometer designed for higher sensitivity
Simultaneously measures VLDL-c, LDL-c, HDL-c & Lp(a)-c
LDL-c and HDL-c compares well with CDC reference methods
Lp(a) compares well with Lp(a) candidate reference method

15. Within-Run with Helena Electrophoretic Method
Pool VLDL-C LDL-C HDL-C
mg/dL mg/dL mg/dL
B 8.1 ± ± ± 1.5
(5.3% CV) (1.3% CV) (3.6% CV)
From: Naito HK, et al. Handbook of Lipoprotein Methods. AACC Press, Washington D.C., Pgs (1997)

16. Comparison of Methods: Helena Electrophoresis vs. CDC Reference Method
Fractions Regression r
VLDL-C y= x
LDL-C y= x
HDL-C y= x
From: Naito HK, et al. Handbook of Lipoprotein Methods. AACC Press, Washington D.C., Pgs (1997)

17. Comparison of Methods: Helena vs. Ultracentrifugation
Fractions Regression r
VLDL-C y= 0.929x
LDL-C y= 1.006x
HDL-C y= 1.158x
Lp(a) y= 0.23x
From: Nauck M, et al. Clin Chem 1995; 41:

18. LDL-c and HDL-c Summary
LDL-C calculation method is not dependable when compared to some of the current direct LDL-C methods.
Ultracentrifugation methods for LDL and HDL still remains the gold standard for accuracy.
The 3rd-generation electrophoresis methods for lipoprotein-C quantitation have several attractive features.
The 3rd- generation direct or homogenous LDL-C and HDL-C methods have better precision but may suffer from lack of LDL or HDL specificity; thus, accuracy may be compromised.

19. LDL-c and HDL-c Summary (cont)
The selection of your instrument-reagent-calibrator system for LDL-C or HDL-C determinations should be based on the approved list of the CDC CRMLN certificate of traceability.
Periodic verification of accuracy of LDL-C and HDL-C should be done, particularly if the reagent and/or calibrator lot number changes.
More robust LDL-C and HDL-C methods should be employed that are not affected by interfering substances (i.e., abnormal lipoproteins, hypertrigly- ceridemia)

20. Lipoprotein(a) Chemistry
Structurally resembles LDL
Has a second large polypeptide, Apo(a)
Is polymorphic in size; Molecular weight kDa
Has 10 types of kringle 4, which is the basis of the different isoform size variability

21. Physiology of Lp(a)
Is an acute phase protein. Apo(a) is made by the liver and is assembled with apo B-100 on the hepatocyte surface. Lp(a) catabolism is unclear.
Compete with plasma plasminogen for binding sites, resulting in decreased synthesis of plasmin and inhibition of fibrinolysis
Increases cholesterol deposition in the arterial wall
Enhances foam cell formation
Makes O2-free radicals in monocytes
Promotes SMC proliferation
Induces monocyte-chemotactic activity in subendothelial space

22. Physiology of Lp(a) (Cont.)
Mechanism of CAD: Atherogenesis and Thrombogenesis
Emerging Risk Factor for Vascular Disease
Most prospective and retrospective studies suggest an independent association between Lp(a) and presence and extent of CAD, premature CAD, MI, restenosis after balloon angioplasty, and CVD.
There is evidence for a benefit of lowering Lp(a)
Response to Intervention Therapy
Diet and exercise have no effect: (maybe with monounsaturated fats or caloric restriction with weight loss)
Effect of statins are controversal
Niacin and aspirin will lower

23. Lp(a) and CHD: Meta-analysis of 27 Prospective Studies
n The study (n = 5436) with a mean follow-up of 10 years showed that if an individual in the general population is in the upper third at baseline, you are at 70% increased risk for CHD compared to persons at the lower one-third.
n The Lp(a) association to CHD risk is significant and is independent of the standard vascular risk factors.
From: Danesh J . Circulation 2000; 102:

24. Lp(a) Increases CHD Risk In Men With Other Risk Factors
n PROCAM Prospective Study: 788 males were followed for 10 yrs; [Lp(a) measured on fresh blood]
n The overall risk of a coronary event was 2.7 times higher if Lp(a) was > 20 mg/dL. The risk increased further if there were other risk factors, I.e., LDL-C > 160 mg/dL, HDL-C < 35 mg/dL, BP > 140/90 mmHg
n CONCLUSION: Lp(a) is an important independent CHD risk factor that aggravates the coronary risk exerted by elevated LDL-C, low HDL-C, hypertension or the combined effects of multiple risk factors (TG, smoking, diabetes, angina pectoris, and family history of MI)
From: Am Coll Cardiol 2001:37:

25. Who Should Have an Lp(a) Test Done?
n Patients with a normal lipid profile, but have documentation of definite CHD (MI, angina, CABAG, angioplasty, stent implants)
n Patients with parents or 1st-degree relatives who died of premature CHD
n Patients with known elevation of Lp(a) or parents with elevation of Lp(a)
n High-risk African American males
n Postmenopausal women
n Men with traditional and/or global CHD risk factors; diabetics and patients with renal disease

26. It All Began with Some Observations by a Clinical Pathologist and a Cardiologist…
Let’s prove it!

27. Clinical Studies
Retrospective study of 1124 subjects with lipoprotein electrophoresis (including Lp (a)) performed in a 26 month period. Lipoprotein electrophoresis performed only when abnormal lipids where found apriori and/or in cardiac patients with high hsCRP/histamine. These patients are followed to date.
Prospective study of CHD compared with healthy subjects matched for age and sex: Distribution according to race and Lp(a).100 patients, (72 w, 28 aa), and 50 healthy subjects.
Prospective study of 51 patients with poorly controlled T2DM before and after treatment with infusion with a external insulin pump.

28. Major Diagnosis
2 major groups: Caucasians + (Hispanics) and African Americans were considered for statistics.
T2DM
CHD
CVD
Other
Caucasians 82 90 20 10
African Amer. 88 84 24 14
CHD: coronary heart disease (MI, angina, coronary insufficiency, angioplasty, bypass surgery, restenosis)
CVD: cerebrovascular disease (ischemic stroke, TIA, brain infarction)
T2DM: Type 2 diabetes mellitus ( nephrotic syndrome)
Other: PAD, chronic renal failure

29. Distribution of Lp(a) Cholesterol According to Race
Caucasians
344 85
184
African Amer. 40 89
210
Hispanics 49 12 20
Asians 42 6 4
Pakistani+
Indians 34 2 3
Total (%)
509 (45.28)
194 (17.26)
421 (37.45)

30. Distribution of Lipids in the Cohort with Lp(a) > 4.1
Chol > 200
TG > 150
HDL < 40
# (%)
Caucasians
130 (37.8)
110 (32.0)
86 (25)
African Amer.
29 (72.5)
14 (35)
16 (40)
Hispanics
15 (30.6)
10 (20.4)
14 (8.6)
Asians
12 (28.6)
8 (19.1)
6 (14.3)
Pakistani+
Indians
30 (88.2)
14 (41.2)
2 (5.9)

31. Distribution of Increased Lipoproteins in the Cohort with Lp (a) > 4.1
VLDL > 35
LDL > 120
HDL < 40
BROAD B
Caucasians #(%)
48 (23.5)
62 (30.4)
40 (19.6)
34 (16.6)
African Amer. #(%)
50 (23.8)
71 (33.8)
38 (18.1)
10 (4.8)

32. Distribution According to Race & Lp(a) (36w, 21aa)
Caucasians
African American
# (%)
0 – 4
25(69.4)
12(57.1)
4.1 – 10
4(11.1)
4(19.1)
> 10.1
7(19.5)
5(23.8)

33. Normal Lp(a) Values Caucasian African American
Lp(a) Non-Diseased Population (Caucasian & African American)
Caucasian
African American
All
Males
Females
Mean
2.6
2.4
2.9
3.4
3.2
3.8 SD
2.8
2.7
3.6
Median
1.9
1.6
2.3
2.2
2.0
95th Percentile
6.2
5.2
6.3
8.6
8.3
% ≥10 mg/dL
98.3
98.8
97.7
97.9
98.2
97.0
Min
0.2
0.4
9.2
Max
11.4
10.9
11.8
11.3
11.5 N
254
146
108
102 56 46

34. Lp(a) Stratified by Risk Score
Diseased Population
Framingham Risk Assessment
All ≤4
5 and 6 7 ≥8
Mean
11.1
3.2
6.6
10.9
14.9 SD
8.7
3.4
5.9
8.8
8.0
Median
7.2
1.9
4.4
9.0
10.6
5th Percentile
2.4
1.5
2.3
4.2
5.4
95th Percentile
22.4
9.8
14.8
18.0
26.3
% ≥10 mg/dL
51.6
22.5
59.4
65.2
Min
0.2
0.6
1.6
3.3
Max
24.4
14.6
23.2
28.8 N
530
103
105
195
127

35. ROC of Lp(a) Cut-offs vs Clinical Sensitivity & Specificity at Framingham Risk Assessment Cut-off of < 4
0.2
2.0
3.9
5.9
8.1
9.9
12.5 15
18.2 20 25 28 40 60 80
100
Area under the curve = ± 0.007
Sensitivity (%)
1-Specificity (%)

36. Cardiovascular Disease is the Leading Cause of Death in the US
CV Cancer Accident Pneumonia AIDS disease Influenza
Millions CP

37. Ischemic Events in the U.S.
1,500,000 heart attacks: 500,000 deaths
500,000 strokes: 150,000 deaths
One third of individuals who experience an
ischemic event will die as a result of that event.
Many who have an event have no prior
symptoms.

38. Prevention of Ischemic Cardiovascular Events is Key!!
How do we determine who will have an ischemic event?
Risk Factors
Age, smoking status, hypertension, diabetes, Cholesterol, HDL.
The ATP-III: NCEP
Provide risk factor screening guidelines and treatment guidelines based on risk factor analysis.

39. Cholesterol Screening: NCEP
Everyone over 20 years of age
Every 5 years
Total Cholesterol
HDL cholesterol
Triglyceride
LDL cholesterol
Treatment guidelines based on LDL cholesterol concentration

40. Cholesterol and Cardiovascular Diseases

42. Prevention of Ischemic Cardiovascular Events is Key!!
One-third to one-half of ischemic events occur in individuals with LDL < 130 mg/dL and in current guidelines for primary prevention the target is < 130 mg/dL.

43. Cardiovascular Risk Factors
There is a need for additional risk factors.
Additional risk factors would improve accuracy of decisions regarding preventative therapies
Rader DJ. NEJM. 2000;343:

44. Platelet actv.
TXA2
12-HETE
B-TBG
P-selectin
Endothelium
Endothelin
Prostacyclin
Nitric oxide
ICAM,VCAM
ADMA
Fibrinolysis
D-Dimer
PAI-I
Plasminogen
Coagulation
Fibrinogen
PF 1+2
TAT
TFPI
TPP
Lipids/Oxidation
LDL subclasses
Lp (a)
F2 isoprostanes
OxLDL
Paraoxonase
Nutrition
HCY
B12,B6
Folate
Vit. C,E,
Carotene
Inflamm.
hsCRP
cytokines
chlamydia
CMV
Lp-PLA2
Homocysteine
Thrombin
monocyte
chemotaxis
ICAM
VCAM
E-selectin
TXA2
Tissue factor
VWF
Native LDL
Growth
Factors
slow
LPC, OxFA
O2 radicals
Lp-PLA2
smooth muscle
cell mitogenesis
Vasoconstriction
rapid
Oxidized LDL

45. Emerging Risk Factors Proposed Panel
Homocysteine
Lipoprotein(a) [Lp(a)]
High-sensitivity CRP
Fibrinogen
Small dense LDL
Currently no guidelines for measurement; may guide intensity of risk reduction therapy in selected patients.

46. Emerging Risk Factors
The NCEP ATP-III panel identified these novel markers and indicated that clinicians may utilize them in selected persons to guide intensity of risk reduction therapy and modulate clinical judgment when making therapeutic decisions.
They do not however, identify in which group of patients these markers are best used or how to respond to elevated values.
JAMA 2001:285;

47. Use of Novel Risk Markers
Mayo Test Volumes: 2003
Homocysteine 58,000
hsCRP 26,000
Lp(a) 22,000
LDL subfractions 3,600
Fibrinogen ?????

48. Mayo Recommendations for use of Extended Risk Marker Panel
Acute coronary syndrome
Increasing risk
>20%
10 year risk
CAD and
CAD risk equivalents
Extended Marker
Panel
10% - 20% 10 year risk
6%-9% 10 year risk
Low risk population

49. Mayo Recommendations for Use of Extended Risk Marker Panel
When to Measure
Use to enhance clinical decision making in persons at intermediate risk for developing an ischemic event as assessed by the Framingham 10 year risk score: 10-20% risk.
Provide with Request
Age, gender, smoking status, blood pressure (treated or untreated)

51. Mayo Recommendations Clinical Response to Elevated Markers
Interpretations are provided with every report of the novel risk marker panel.
Interpretations are made by doctoral level staff in Laboratory Medicine or in the Mayo Cardiovascular Health Clinic.
Interpretations include a description of abnormal values, as well as suggestions for appropriate treatment, given the noted abnormalities.
A separate document describing up to date information on the background, interpretation and recommended therapy for abnormalities of each of the risk markers is included with the report.

52. Novel Risk Markers Relation to Angiographic CAD and Events
504 consecutive patients undergoing
coronary angiography
Vessel Disease 3V
None 2V
Mild 1V
Mean Age 60 ± 11 years, 62% Male
46% patients have none or mild coronary occlusion
54% patients have significant occlusion (>50% stenosis)
Median Follow-up: 4 years

53. Patient Demographics Age (yr) 60±11 Male (%) 62 Hypertension (%) 46
BMI (kg/m2)
29±6
Prior infarction (%) 15
Heart failure (%) 12
Significant CAD (%) 54
ACS (%) 34

54. Study Population Indication for coronary angiography
Acute coronary syndrome (34%)
Positive stress test (25%)
Exertional dyspnea (27%)
Other (14%)

55. Aims To analyze for associations between
novel risk factors including Lp-PLA2 and:
Other CAD risk Factors
(both traditional and emerging)
Acute coronary syndromes
Angiographic CAD
Clinical outcomes

56. Lipoprotein Associated Phospholipase A2 (Lp-PLA2)
AKA: Platelet-activating factor acetylhydrolase
50kDa, Ca-insensitive lipase
Produced predominantly by macrophages and contributes to foam cell formation
> 80% bound to LDL
Not responsive to IL-1, IL-6, TNF-alpha.
Hydrolyzes oxidized phospholipids

57. Multivariate Logistic Regression Analysis
After adjusting for age, gender, smoking history, hypertension, cholesterol, HDL cholesterol, and triglyceride, Lp-PLA2 was no longer was no longer independently predictive of angiographic CAD.
CRP was not predictive of CAD in either the univariate or multivariate model.
Data Presented at American College of Cardiology Annual Meeting, March 2003.

58. HR For Angiographic CAD: Multivariate
Variable HR 95% CI P-Value
Age <0.0001
Male Gender – 6.60 <0.0001
Hypertension
Smoking
Total cholesterol
HDL cholesterol
Log triglyceride
Log CRP
Fibrinogen
Lp-PLA
Lp(a) protein (per 20 mg/dL)
Lp(a) cholesterol (per 5 mg/dL)

59. Lp(a) Cholesterol Electrophoresis Helena Laboratories
LDL
VLDL
HDL
Lp(a) UC
Non-UC
Sample 1
Sample 2
Sample 3
Sample 4
Sample 5
UC Lp(a) = 6
Non-UC Lp(a) = 8
Lp(a) mass = 125
UC Lp(a) = 8
Non-UC Lp(a) = 19
Lp(a) mass = 131
UC Lp(a) = < 2
Non-UC Lp(a) = < 2
Lp(a) mass = <7
UC Lp(a) = 19
Non-UC Lp(a) = 21
Lp(a) mass = 72
UC Lp(a) = <2
Non-UC Lp(a) = <2
Lp(a) mass = 11
Lp(a) cholesterol
can be measured
in whole serum
Verified in samples
from 470 subjects
Baudhuin, et.al., Clinical Biochemistry: 2004

60. Immunologic Lp(a) vs. Lp(a) Cholesterol

61. HR for Events in 425 Non-AMI: Univariate
Variable HR 95% CI
Age – 2.13
Male Gender
Hypertension
Smoking
LDL cholesterol
HDL cholesterol
Log triglyceride
Log CRP
Log HCY
LDL size
Fibrinogen
Lp-PLA
Lp(a) protein: > 30 mg/dL
Lp(a) cholesterol: detectable – 4.03

62. HR For CVD in 425 non-AMI: Multivariate
Variable HR 95% CI
Age
Male Gender
Hypertension
Smoking
LDL cholesterol
HDL cholesterol
Log triglyceride
Log CRP
Log HCY
LDL size
Fibrinogen
Lp-PLA
Lp(a) protein: > 30 mg/dL
Lp(a) cholesterol: detectable

63. Lipoprotein (a) Structure
Inactive
cleavage
site
H2N
HOOC S K5 K4
T10
T 9
T 8
T 7
T 6
T 5
T 4
T 3
T 2
ApoB-100 T1
Kringle (~13 KDa, ~80 AA) 4 3 5 2 1
Cleavage site
by pg activator
Plasminogen (pg)
Apo (a):
-- Sequence homology to plasminogen (genetic variant)
-- Size heterogeneity (~ KDa; 3-40 K4-T2 repeats)

64. Apolipoprotein (a) Isoform Identification by Western Blotting
M S S S
>S4 S4 S3 S1 B
Apo (a) Size Standards:
>S4: KIV repeats, >700 kDa
S4: KIV, ~700 kDa
S3: KIV, ~650 kDa
S1: KIV, >Apo B-100 (512kDa)
B: KIV, <Apo B-100
1- 5: Patient Serum Samples
M: Protein Size Marker, Myosin band (207 kDa)

65. Apolipoprotein (a) Isoforms23
and 31 S 12 20
and 27 S 21 16 S

66. Overview and Conclusions
Prevention of Cardiovascular events is Key!!!
Know Your Cholesterol, Know Your Risk
Lipid profile in everyone > 20 years of age
Use ATP III guidelines
Determine Framingham Risk Score
Educate Others
Novel/Emerging Risk Markers
Primarily in patients at intermediate risk
Guide intensity and type of therapy
Much more work needs to be done

67. Conclusions
Lp-PLA2 is emerging as an independent risk marker for cardiovascular events: orally active specific inhibitors make it a potential therapeutic target.
Lp(a) cholesterol is a strong marker for angiographic coronary disease as well as cardiovascular events.
Differences observed between Lp(a) cholesterol and Immunologic Lp(a) mass assays need to be further investigated, but may be due to dependance of the mass assays on apo(a) isoform size
Efforts to standardize Lp(a) methods need to continue.

68. Lipid Profiles Medicare-approved panel Candidate additional analytes
Total Cholesterol, Triglycerides, LDL-c, HDL-c
Candidate additional analytes
ApoA, ApoB, IDL, Lp(a), LDL Sub, HDL Sub, RLP

69. Panel Comparison 266 consecutive subjects
45% had desirable TC, TG by NCEP
Of those, 44% had Lp(a) above 55th percentile
28% had Lp(a) above 75th percentile
28% had desirable TC, TG, LDL-c, HDL-c
Of those, 49% had Lp(a) above 55th percentile

70. Lp(a) Correlates
None of the following are correlates or predictors of Lp(a) values:
Total cholesterol
LDL-c
HDL-c TG
Apo A1
Apo B100

71. Lp(a)/Lp(a)-c and Platelet Function
Study of 100 subjects with existing Lp(a) and Lp(a)-c measurements
Lp(a) ranged from <5-231 mg/dL
Lp(a)-c ranged from mg/dL
Measured platelet aggregation to collagen/ADP and collagen/EPI by PFA
Medication history: 34% on ASA or NSAIDS

72. Results
Closure times with either EPI/collagen or ADP/collagen were not decreased as Lp(a) concentrations increased
No difference between Lp(a) and Lp(a)-c