From the Guidelines
Primary care physicians (PCPs) should not routinely order lipoprotein(a) (Lp(a)) or apolipoprotein B (ApoB) for cardiovascular risk assessment, but rather consider advanced lipid testing in specific clinical scenarios. When evaluating cardiovascular risk, the current guidelines recommend a 3-tiered decision process for treatment in adults aged 40 to 75 years with borderline or intermediate risk for atherosclerotic cardiovascular disease (ASCVD) 1. The decision to order advanced lipid tests such as Lp(a) or ApoB should be based on individualized risk assessment, taking into account factors such as family history of premature ASCVD, LDL-C levels, metabolic syndrome, and chronic kidney disease, among others 1. Key considerations for ordering Lp(a) include:
- Patients with premature cardiovascular disease
- Family history of early heart disease
- Inadequate response to standard lipid management Key considerations for ordering ApoB include:
- Certain cases where HDL function needs to be better assessed, such as very low HDL levels or unusual cardiovascular presentations despite normal standard lipid profiles
- When the clinical judgment requires additional information about cardiovascular risk beyond traditional lipid measurements In general, a standard lipid panel, which includes total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides, is the first-line test for cardiovascular risk assessment, and advanced lipid testing should be reserved for specific clinical scenarios 1.
From the Research
Lipid-Lowering Therapies
- The decision to order Lipoprotein B (Lp-B) or Apolipoprotein A (Apo A) should be based on the patient's individual risk factors and lipid profile 2, 3, 4.
- Statin therapy is the primary treatment for lowering low-density lipoprotein cholesterol (LDL-C) and reducing the risk of atherosclerotic cardiovascular disease (ASCVD) 2, 5, 6.
- Apolipoprotein B (ApoB) and non-high-density lipoprotein cholesterol (non-HDL-C) are secondary targets for lipid-lowering therapy and may be more accurate markers of residual risk than LDL-C in statin-treated patients 3, 4.
Monitoring Lipid Levels
- Lipid monitoring after initiation of lipid-lowering therapies is important to assess adherence and medication efficacy 5.
- The 2018 AHA/ACC Multisociety cholesterol guideline recommends a lipid panel after initiating lipid-lowering therapy to monitor adherence and medication efficacy 5.
- LDL-C assessment after initiating lipid-lowering therapy should be reinstated as a performance measure for patients with ASCVD 5.
Safety and Efficacy of Statin Therapy
- Statin therapy has been shown to be safe and effective in both primary and secondary prevention of cardiovascular disease 6.
- The benefits of statin therapy far outweigh any real or perceived risks, including the risk of new-onset diabetes mellitus, cognitive impairment, and haemorrhagic stroke 6.
- Clinicians should be reassured about the safety of statins and should not hesitate to initiate or continue statin therapy in patients who require it 6.