Objective The purpose of this case study was

Objective • The purpose of this case study was to illustrate the importance of measuring LDL-P. • To show the discordance between LDL-P and LDL-C concentrations. • To show the effect of lipid lowering therapies both on lipoproteins and cholesterol/TG concentrations. 2

• A healthy 57 year old Caucasian woman (BL) with family history of premature coronary artery disease (CAD) presented for preventive screening to her primary care physician. • She reported eating a healthy diet, exercising regularly and consuming minimal alcoholic beverages. • Her mother and sister have CAD and had coronary bypass surgery (CABG) at ages 52 and 53, respectively. • Lipid panel revealed the following: - Total cholesterol 250 mg/d. L - LDL-C 110 mg/d. L - HDL-C 116 mg/d. L - Triglyceride 29 mg/d. L - non-HDL-C 134 mg/d. L - Framingham risk score (10 years)- 3% 3

• Two months after this screening test BL experienced an episode of atypical chest pain. She was evaluated in the emergency room (ER). No cardiac work-up was performed as she responded to treatment with antacids and proton pump inhibitor therapy. • Two weeks later she again began to experience non-exertional, atypical chest pain. She was again evaluated in the ER and at this time had an abnormal electrocardiogram, and subsequent heart catheterization showed coronary disease with 70% blockage in the left anterior descending artery and diffuse disease in multiple vessels. • She underwent triple vessel coronary artery bypass surgery. • Upon discharge, her cardiologist placed her on atorvastatin 40 mg, 1 gram omega 3 fatty acids, aspirin 81 mg and clopidagrel 75 mg per day. 4

• One month later she was evaluated in a lipid clinic. • BL’s lipid panel, on atorvastatin 40 mg, 1 gram omega 3 fatty acids, aspirin 81 mg and clopidagrel 75 mg per day, revealed the following: - Total cholesterol 203 mg/d. L - LDL-C 141 mg/d. L - HDL-C 44 mg/d. L - Triglyceride 89 mg/d. L - Non-HDL-C 159 mg/d. L 5

• Lipidologists ran an NMR profile on the patient • Her NMR lipoprotein test results: • LDL-P 3002 nmol/L (high- goal less than 1000 nmol/L) • Small LDL-P 3002 nmol/L • LDL-P size-19. 1 nm (small) 6

• Four months later, after a nine pound weight loss and switching to rosuvastatin. • The following were her lab numbers: - LDL-P 1418 nmol/L - Small LDL-P 992 nmol/L - LDL-C 110 mg/d. L - HDL-C 100 mg/d. L - Triglycerides 83 mg/d. L - Total cholesterol 227 mg/d. L - Non-HDL-C 127 mg/d. L 7

• Six months With known disease, added extended release niacin 500 mg. On rosuvastatin 40 mg, OM 3 1 gm, clopidogrel 75 mg. • The following were her lab numbers: - LDL-P 965 nmol/L - Small LDL-P 661 nmol/L - LDL-C 86 mg/d. L - HDL-C 152 mg/d. L - Triglycerides 60 mg/d. L - Total cholesterol 250 mg/d. L - non-HDL-C 98 mg/d. L 8

• 12 months with known disease, increased extended release niacin to 1 g. Still on rosuvastatin 40 mg, OM 3 1 gm, clopidogrel 75 mg. • The following were her lab numbers: - LDL-P 616 nmol/L - Small LDL-P 438 nmol/L - LDL-C 129 mg/d. L - HDL-C 111 mg/d. L - Triglycerides 59 mg/d. L - Total cholesterol 252 mg/d. L - non-HDL-C 141 mg/d. L 9

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How About Ratios? Initial Visit 12 month Visit TC/HDL-C 2. 15 2. 27 LDL-C/HDL-C 0. 94 1. 16 TG/HDL-C 0. 25 0. 53 12

Conclusion • Many patients with low or moderate LDL cholesterol levels still experience CHD (coronary heart disease) events (Residual Risk). • LDL cholesterol (LDL-C) is the traditional measure of LDL quantity, chosen for historical, not analytic or clinical reasons. • Even in the presence of a high HDL-C, a more extensive evaluation may identify CV risk factors. • By utilizing lipoprotein information, appropriate patient selection will identify those who should receive suitable medication 13