earlymedical15.1. Discussing ASCVD with our Patients: A conversation between Tom Dayspring and Peter
Intro
Before we review lipid labs with a patient for the first time, we like to provide a thorough background on the chemistry and physiology of cholesterol. A good image is worth a thousand words, so we wanted to share some excellent diagrams as we demystify the complexities of cholesterol, lipoproteins, and atherosclerotic cardiovascular disease (ASCVD). In addition to the information essential to understanding ASCVD and labs, we also review three case studies to show real examples of how we determine an individual’s treatment options for managing ASCVD based on the nuances of their labs.
Pathophysiology of ASCVD
To understand the complexities of ASCVD, we start from the basics by defining the biologically important lipid molecules, the role of lipoproteins, and the formation of low-density lipoprotein (LDL) particles. Here we discuss how apolipoprotein B (apoB) plays a significant role in the development of arterial plaques, other risk factors for ASCVD, and the role of the liver in regulating plasma LDL concentration. Although it is a standard measurement, we explain why LDL cholesterol is an imperfect measure of ASCVD, and why measuring the number of apoB-containing particles is a better measurement.
Understanding a Standard Lipid Profile
Generic lipid profiles can provide some insight into your risk of ASCVD. Here we review the components of a generic lipid panel, describe the surrogate measures for apoB (and why they are only estimates), and debunk the very common misconception that there is “good” and “bad” cholesterol.
Understanding an Ideal Lipid Profile
A more comprehensive lipid profile can provide insight into other conditions. For example, there is a strong relationship between metabolic dysfunction and ASCVD. Suboptimal lipid values can be indicative of metabolic dysfunction long before a diagnosis of type 2 diabetes. Here we review what we believe constitutes the optimal ranges or levels for a comprehensive lipid panel, including measurements of metabolic and inflammatory markers, and we discuss the impact of lifestyle interventions.
Understanding Sterols
Cholesterol is a member of the larger family of lipids known as sterols. Here we review the findings of a sterol panel and describe why the elevation of sterols can explain some of the mechanisms that lead to increased plasma cholesterol levels and, more importantly, how this insight can drive treatment options.
Understanding an Omega 3 Index
The omega-3 index is another biomarker to assess ASCVD risk. Here we review the measurement and associated ranges. Additionally, we discuss ways to increase your omega-3 index, including through supplementation.
Therapeutic agents to manage CVD
Just as with the very notion of cholesterol, there are several misconceptions around lipid-lowering therapies—statins in particular. However, statins are one of the most heavily researched classes of pharmacotherapies. Here we explain the mechanisms of action, discuss the efficacy and dose-dependent effects, and review the risks and benefits of each from the outcome data of large clinical trials for available lipid-lowering therapies.
Patient X Case Study and Risk Assessment
The next few videos are real-world examples that help demonstrate the reasoning and execution of a treatment plan based on a patient’s risk assessment. The first case study is a 58-year-old male with metabolic disease and significant risk factors for ASCVD. Here we review his current labs and potential therapeutic options for addressing risk factors including lifestyle changes and medications for lowering blood pressure and apoB.
Patient Y Case Study and Risk Assessment
Patient Y Case Study and Risk Assessment The second case study is a 44-year-old woman with a positive calcium scan who is currently on statin therapy. Here we review her current labs and her other risk factors for neurodegenerative disease, and we discuss changes in therapeutic options that would reduce apoB while minimizing any increase in risk for Alzheimer’s disease.
Patient Z Case Study and Risk Assessment
The last case study is a 35-year-old male with dyslipidemia, elevated Lp(a), and genetic predisposition towards hypercholesterolemia and hypertension. Here we discuss the impact of genetically elevated Lp(a) and review this patient’s history, current medications, and changes made to his therapeutic regimen.
Outro
OutroThere is a firehose of information in these videos, so don’t worry if you only took away a small portion of the important points. The intention is for these videos to be a resource that you can revisit as often as you like.