Cardiovascular disease (CVD) is a leading cause of mortality worldwide, contributing to 17.9 million deaths annually and accounting for 31% of global deaths. This article will explore an important aspect of cardiac risk assessment: advanced lipid testing.
While traditional cholesterol tests provide valuable insights, advanced lipid testing offers a more detailed perspective on cardiovascular health. This article explains how these tests work, what they measure, and how they can empower individuals to understand and manage their cardiac risk.
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Traditional vs. Advanced Lipid Testing
The standard lipid panel includes total cholesterol, high-density lipoprotein (HDL), low-density lipoprotein (LDL), and triglycerides.
While this panel is important for understanding CVD health, it may not fully capture CVD risk, potentially leading to mismanagement (21).
Advanced lipid testing provides more detailed insights into CVD risk by assessing specific lipid particles in the bloodstream. It evaluates the size, density, core lipid composition, and particular apolipoproteins involved in the development of atherosclerosis and CVD (42).
Key Components of Advanced Lipid Testing
The following advanced lipid markers are important for assessing cardiovascular health.
LDL Particle Number (LDL-P)
What is this marker?
Low-density lipoprotein particle number (LDL-P) measures the concentration of LDL particles in circulation. LDL-P is involved in atherosclerosis and cardiovascular disease progression and may provide more accurate insights into CVD risk than LDL cholesterol (45).
Why is this an important marker to measure?
The development of atherosclerosis is influenced by inflammation levels (hs-CRP), insulin resistance, and lipid levels.
LDL is the traditional biological marker for CVD risk. LDL does not account for insulin resistance and can be normal in individuals who are still at risk for a cardiovascular event (stroke, heart attack, aneurysm).
LDL-P may provide more accurate insights into CVD risk than LDL because it measures the number of atherogenic particles in the blood (47).
HDL Particle Size
What is this marker?
High-density lipoprotein (HDL), or the "good cholesterol," helps remove atherogenic lipids from the bloodstream. HDL particles can vary in size, with some larger and others smaller.
The size of HDL particles is inversely related to the risk of CVD, with larger HDL particles potentially associated with reduced cardiovascular risk and smaller HDL particles potentially associated with increased risk of CVD (36).
Why is this an important marker to measure?
Measuring HDL particle size can provide valuable insights into an individual's cardiovascular health and risk of heart disease. Understanding the size of HDL particles can help guide treatment more effectively. This test can also show variations in CVD risk for those with normal HDL levels (36).
Lipoprotein(a), or Lp(a)
What is this marker?
Lipoprotein (a), also known as Lp(a), is a form of LDL that is a genetic risk factor for developing atherosclerosis, coronary artery disease, thrombosis, and stroke.
Lp(a) levels are highly correlated with LPA gene mutations. Lp(a) may influence atherosclerosis by affecting fibrinolysis, a process that helps manage blood clots. Lp(a) also influences the production of foam cells, which are involved in plaque formation (26).
Why is this an important marker to measure?
Lp(a) is an important screening tool for those with a family history of cardiovascular disease without other major risk factors. Lp(a) is considered one of the most atherogenic particles in circulation and helps identify individuals who may benefit from more intensive lipid-lowering therapy (26).
Apolipoproteins ApoB and ApoA-I
What are these markers?
Apolipoprotein B (ApoB) plays a role in plaque formation and contributes to atherogenesis and cardiovascular disease risk. ApoB is a carrier molecule for "bad" cholesterol, such as LDL, very low-density lipoprotein (VLDL), and low-density lipoprotein (IDL).
ApoB levels indicate the atherogenic particle concentration of total cholesterol. It may provide more accurate insights into cardiovascular disease risk than total or LDL cholesterol (7, 26).
Apolipoprotein A1 (ApoA1) is the major protein component of HDL (good cholesterol). ApoA1 helps remove bad cholesterol from the body, supporting the management of atherosclerosis. ApoA1 also plays a role in mediating inflammation, immunity, and nitric oxide production (27).
Why are these important markers to measure?
Measuring ApoB and ApoA1 is important because an individual may have normal LDL and total cholesterol. An imbalance in the ApoB/ApoA1 ratio may indicate an increased risk of cardiovascular disease. The ApoB/ApoA1 ratio may provide more accurate insights into cardiovascular disease risk in those with blood lipids within the normal range (39).
How Advanced Lipid Testing Improves Cardiac Risk Assessment
Traditional lipid testing and comorbidities can be used to estimate an individual's 10-year risk for developing future cardiovascular disease. The current model of assessing CVD risk based on traditional lipid testing may not fully capture risk for up to 10% of individuals.
Incorporating advanced lipid testing may improve risk estimations and help identify genetic disorders that may be missed with traditional lipid testing. Utilizing Lp(a) and LDLR gene testing can help identify genetic lipid disorders that may not be diagnosed with traditional lipid testing (9).
Interpreting Advanced Lipid Test Results
Interpreting the results of advanced lipid tests can be complex. The following is a guide to understanding each value and its potential impact on cardiac health (28, 56):
- LDL Particle Number: A measure of the concentration of LDL particles in circulation. Elevated levels may be associated with an increased risk of CAD (even with normal LDL). Elevation in LDL-P should also prompt a workup for metabolic syndrome and insulin resistance.
- HDL Particle Size: Lower HDL particle size may correlate with an increased risk of CVD. Practitioners may aim to see HDL particle size increasing throughout lipid-lowering treatment.
- Lipoprotein (a) or Lp(a): Lp(a) is an independent genetic risk factor for CVD, with little to no influence by lifestyle factors. Inflammatory conditions such as pregnancy, hypothyroidism, growth hormone therapy, and kidney disease may cause elevation.
- ApoB & ApoA1 Ratio: These two markers are generally reported as a ratio. ApoB measures the particles that may lead to atherosclerosis, and ApoA1 measures the particles within HDL particles, which aid in removing bad cholesterol from the body. A lower ratio may correlate with a lower risk of CVD.
Using Advanced Lipid Tests to Guide Treatment
Lifestyle Modifications
- Regular physical activity may increase HDL, aiding in the management of LDL particles in circulation. To support healthy lipid levels, 150 minutes of moderate-intensity exercise per week is often suggested.
- Obesity may contribute to elevated lipids through various mechanisms. Weight loss and following a healthy diet may increase the proportion of large HDL-P, which is associated with decreased CVD risk.
- LDL particles may be more sensitive to dietary modification than other lipid markers. Following a Mediterranean diet may help manage the number of LDL particles in circulation.
- Reducing alcohol intake: For those with elevated lipid profiles, it may be beneficial to consume less than 10 g/day (1 drink).
(28)
Pharmacological Interventions
- According to the ASCVD Risk Calculator, statin therapy is often considered for individuals whose LDL is greater than 190mg/dL, those with diabetes mellitus, and those 40-75 years of age at high risk (6).
- PCSK9 inhibitors may be recommended for patients with genetic familial hypercholesterolemia (LPA gene mutation, PCSK9 gene mutation, APOE gene mutation).
- For elevated Lp(a) levels, niacin, PCSK9 inhibitors, and Mipomersen have shown potential in managing Lp(a) levels.
- Nicotinic acid, statins, and bile acid sequestrants may be considered for patients with elevated LDL particle numbers.
- Statins may show minimal effects on patients with decreased large HDL particle levels; thus, nicotinic acid and fibrates may be recommended.
- Bile acid sequestrants and nicotinic acid may be considered for patients with elevated ApoB levels. (46)
How to Get Advanced Lipid Testing
Rupa Health offers various options for advanced lipid testing:
- CardioPro Advanced by Access Med Labs
- Cardiovascular Risk Profile by Doctor's Data
- CardioMetabolic - Expanded by BostonHeart Diagnostics
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Key Takeaways
- Advanced lipid testing offers a comprehensive cardiac risk assessment beyond a traditional cholesterol panel.
- Analysis of LDL particle size, genetic mutations, and HDL functionality provides a more detailed understanding of individuals' risk factors for heart disease.
- Incorporating lifestyle changes, such as physical exercise and proper diet, is important in supporting cardiovascular health.
- Discuss advanced lipid testing with your healthcare provider to explore specific strategies and treatment plans to enhance cardiovascular health.
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