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Testing & Procedures
Advanced Lipid Tests
These components are used routinely in general medical practice to assess risk of atherosclerosis and its complications such as heart attack, stroke, and blockages of large arteries which carry blood to the legs, kidney and various vital organs. In fact, national guidelines for the diagnosis and treatment of high cholesterol in adults, issued by the National Cholesterol Education Panel (NCEP) Adult Treatment Panel (ATP), use the components of the lipid panel in their recommendations for risk assessment and treatment of high cholesterol.
Advanced Lipid Tests are blood tests which give more “cholesterol” information than the lipid panel alone. The results are used to better estimate atherosclerotic risk and to guide us in setting more precise and individualized treatment goals. Besides “cholesterol”, this category also includes blood tests to assess so-called “novel risk factors” for atherosclerosis. Some of these tests diagnose genetic(inherited) risk factors, some assess inflammation, and some are useful aides in selecting which medications may be most effective in a particular case.NMR LipoProfile
The NMR LipoProfile is considered by many cholesterol specialists to be the “gold standard” for lipoprotein analysis, prediction of cardiovascular disease (CVD) risk, setting treatment goals, and for selecting the most appropriate drug therapy for individual patients. This test utilizes a chemical analytical method called “nuclear magnetic resonance spectroscopy”, or NMR spectroscopy. Traditional chemical methods measure the amount of cholesterol carried in the blood within different particles, called lipoproteins, such as LDL and HDL. The traditional lipid panel reports the results as LDL-cholesterol (“bad cholesterol”) and HDL-cholesterol (“good cholesterol”). NMR, however, measures the number, or concentration, of lipoprotein particles as well as the size of such particles. This is important because mounting evidence suggests that the number and size of lipoprotein particles are more powerful predictors of risk, and more appropriate targets of therapy, than the traditional lipid panel. The NMR LipoProfile is reported as 5 major components:
The number of LDL particles that carry cholesterol is a more important risk indicator than the amount of cholesterol in the blood. Also, the size of the LDL particles that carry cholesterol is a key factor, because smaller particles are “more risky” than larger ones. For example, a person with a certain level of LDL-cholesterol(“bad cholesterol”) is at more risk if the LDL particle number is high, compared to another person with the same level of LDL-cholesterol, but with a lower LDL particle number. The first person has a relatively high number of smaller LDL particles compared to the lower number of larger LDL particles in the second case. In most cases, the highest priority of treatment is to lower LDL particle number.
Appropriate lifestyle modifications and medications to lower LDL particle number are the same as those used to lower LDL-cholesterol. The strategy to lower small LDL particle number, however, is often two-pronged. First, efforts are directed at lowering LDL particle number, a component of which is a variable amount of small particles.
HDL particle number is measure of the “good part of the good cholesterol”. This measure is a superior predictor of CHD risk compared to the HDL-cholesterol typically reported as part of a traditional Lipid Panel. Therapeutic lifestyle change and certain medications can be employed to boost HDL particle number.
Finally, large VLDL particle number is an indicator of the level of a risky lipoprotein that carries triglycerides in the blood. Measures to address this lipoprotein are identical to those used to treat high triglycerides.
It should also be noted that the latter 3 components of the NMR LipoProfile, namely LDL particle size, large HDL particle number, and large VLDL particle number, are what are sometimes referred to as lipoprotein indicators of the metabolic syndrome. These components are sensitive to body weight, diet and activity level. Abnormalities of these three lipoprotein components are associated with an increased chance of developing type II , or adult onset, diabetes mellitus in the future.
For more information on the NMR LipoProfile, go to www.LipoScience.com.
Lipoprotein(a) concentrations are genetically determined, though there is recent evidence that dietary trans-fats can (likely need over one gram daily) increase Lp(a). There are many different inherited variations of Lp(a), some higher risk than others. Lp(a) levels are reportedly higher in African Americans than in Caucasian Americans, but the kind of Lp(a) that is typically found in African Americans is usually “less risky” than that found in Caucasions.
Current data indicate that Lp(a) is a risk marker for cardiovascular disease (CVD), rather than a risk factor, as there has been no demonstration of CVD risk reduction by lowering Lp(a). Hence in patients with elevated Lp(a) levels, treatment should target control of LDL cholesterol , or “bad cholesterol”, and other CVD risk factors, rather than Lp(a) per se. The LDL goal should be individualized according to a patient’s overall CVD risk, but elevated Lp(a) is an important consideration in deciding how low to treat the “bad cholesterol”. Most LDL cholesterol-lowering drugs, such as statins, are not effective in lowering Lp(a), but are used nonetheless to achieve an optimal LDL-cholesterol target.
Lp(a) levels can also be influenced by a woman’s hormonal status. Both estrogen and progesterone, the two main “female hormones”, tend to decrease Lp(a) in women. Accordingly, Lp(a) may increase, sometimes dramatically, after menopause. In those cases, post-menopausal hormone replacement therapy may result in significant lowering, and sometimes normalization of, Lp(a). Indeed there are some limited data to suggest cardiovascular benefit in postmenopausal women with elevated Lp(a) who choose to take hormone replacement therapy (HRT). The decision to use HRT at menopause is, however, a very complex one. Lp(a) status is only one of many considerations in choosing whether or not to take hormone(s). The decision should be made with the counseling and advice of a qualified physician, well-versed in the multiple factors to be considered, and familiar with the details of the patient’s personal and family medical history. This is typically the patient’s primary care physician or gynecologist.
Apolipoprotein E Genotype
The E4 form is associated with increased cholesterol levels and increased susceptibility to cardiovascular disease. Persons with APO E4 gene are known to be more sensitive to dietary fat and cholesterol. Studies indicate that the presence of an Apo E4 gene increases the odds of CHD by a factor of about 1.4 in men and 1.8 in women, with higher risk associated with having an Apo E4 pair. The Apo E4 variant is also a risk factor for late onset Alzheimer’s disease. One study found the following risks of Alzheimer’s disease compared to an individual with an E3/E3 pair:
The E2 form is associated with high triglycerides and the E2/E2 pair can be associated with very high cholesterol/triglycerides, increased risk for cardiovascular disease, and increased risk for pancreatitis (an inflammatory condition of the pancreas which can be very serious or even fatal). Certain medications are more effective than others in treating patients with the E2/E2 variant.
Angiotensin Converting Enzyme (ACE) Genotype
High Sensitivity C-Reactive Protein (HS-CRP)
An elevated HS-CRP , then, is an additional risk factor for heart attack. In fact, studies indicate that a person with a high HS-CRP and low “bad cholesterol”(LDL-cholesterol) is at about the same risk for a cardiovascular event as another person with low HS-CRP and high “bad cholesterol”. Therefore lifestyle interventions and drug therapies are often aimed not only at reducing cholesterol levels, but also at decreasing the level of HS-CRP.
Lipoprotein-Associated Phospholipase A2 (Lp-PLA2)
DEXA Body Composition Analysis
If you do strength training twice weekly (i.e. weight lifting) you derive 85% of the benefit as four times weekly.