1. Lipoprotein Management

2. Step 1: Assess clinical CHD risk (Very-High, High, Moderately-High, Moderate, Low Risk) Step 2: Establish goals of therapy appropriate for degree of clinical risk present (Lipids and LDL Particle Number) Step 3: Laboratory evaluation Step 4: Consider therapeutic lifestyle changes and medications as indicated to achieve targets: Primary target: LDL Secondary targets: HDL and TG Step 5:Assess response to therapy and modify intervention as indicated to achieve LDL-P target Approach to Use of Lipids and LDL Particle Number in Clinical Practice Cromwell WC et al. Lipid and Lipoprotein Disorders: Current Clinical Solutions Baltimore: International Guidelines Center; 2009.

3. Assess Clinical Risk Cromwell WC et al. Lipid and Lipoprotein Disorders: Current Clinical Solutions Baltimore: International Guidelines Center; 2009.

4. Establish Goals of Therapy 1. Contois JH et al. Clin Chem. 2009;55:407-419 2. Cromwell WC. In: Clinical Challenges in Lipid Disorders.Toth PP, Sica DA, editors. Oxford: Clinical Publishing; 2008.p. 249-59. 3. Cromwell WC, Barringer TA. Curr Cardiol Reports 2009;11(6):468-475 * More aggressive LDL lowering may be necessary based on clinical judgement.

5. Laboratory Evaluation 1.Fasting Lipid Profile, LDL Particle Number 2.Additional testing as indicated to evaluate secondary causes of dyslipoproteinemia TSH Fasting glucose HbA1C Bun Creatinine Urinalysis Liver Function Tests 3.May consider additional laboratory studies to further assess risk or direct therapy hs-CRP Lp-PLA2 Lp(a) Additional lipoprotein analysis (size, subclasses) Cromwell WC et al. Lipid and Lipoprotein Disorders: Current Clinical Solutions Baltimore: International Guidelines Center; 2009.

6. Treatments That Alter Cholesterol Content of LDL Change LDL-C and LDL-P Differentially Cholesterol per particle decreases with: Statins Statin + Ezetimibe or Bile Acid Sequestrants Estrogen Replacement Therapy Anti-retrovirals (some) Low fat, High carb diet Therapy LDL-C More Than LDL-P Cholesterol per particle increases with: Fibrates Niacin Pioglitazone Omega 3 FAs Exercise Mediterranean and low carb diet Therapy LDL-P More Than LDL-C Little Change in Cholesterol per Particle with: Bile Acid Sequestrant or Ezetimibe Monotherapy Similar Change in LDL-C and LDL-P Cromwell WC. In: Clinical Challenges in Lipid Disorders.Toth PP, Sica DA, editors. Oxford: Clinical Publishing; 2008.p. 249-259.

7. Pharmacologic Options for Reaching Lipid and LDL Particle Number Goals Cromwell WC, Barringer TA. Curr Cardiol Reports 2009;11(6):468-475.

8. Assess Response to Therapy 1.If not at Lipid and LDL Particle Number goal – modify therapy and repeat laboratory tests in 3 months 2.Following therapeutic changes, repeat laboratory testing every 3 months until goal values for lipid and LDL Particle Number are achieved 3.Once at goal – continue therapy and repeat laboratory tests in 1 year Cromwell WC, Barringer TA. Curr Cardiol Reports 2009;11(6):468-475.