Controversies in New Treatment Measures for Metabolic Syndrome

Should measures of lipoprotein levels and LDL particle size be taken into account when treating cardiometabolic issues?

The complexity of metabolic syndrome in cardiovascular disease calls into question what the most accurate markers for predicting personal risks should be. A panel discussion, featured at the Cardiometabolic Health Congress 2010, focused on case reports to discuss varying opinions on proper therapeutic strategies and testing.

On the panel was: Kathy Berra, MSN, ANP; Deepak Bhatt, MD; Tara Dall, MD; and Robert Eckel, MD. The session was moderated by Christie Ballantyne, MD.

Among the case reports highlighted were the following: A 56-year-old white female presents with a normal lipid panel, with HDL 116 mg, LDL 110 mg, triglyceride 29 mg, and non HDL 134 mg. The patient was very fit and in excellent condition, but had a family history of cardiovascular disease. To prevent cardiac events, the patient made sure to take precautions, eating a healthy diet, and getting plenty of exercise.

A few months later, however, she began to have atypical chest pain and had an EKG taken that showed abnormal activity. The patient had to have bypass surgery, much to her surprise. She was given atorvastatin and omega 3. The patient entered the clinic of lipidologist Tara Dall, on the panel. Her new lipid panel was: LDL 141, HDL 44, triglycerides 89, her lipoprotein(a) was 76.

Dall took an NMR LipidProfile test, which measures LDL particle number and size of particles along with direct measures of HDL and VLDL. She also measured ApoB levels, Lp(a) levels, and more. The more advanced testing is a point of controversy for the field, in that questions remain whether these tests should be required or are needed for effective treatment.

The patient’s LDL particle levels were very high at 3001.The team also measured the patient’s TSH levels and CRP — which was very high at 47. The team treated her by switching to rosuvastatin and omega 3-2 mg a day.

The patient then experienced a drop in LDL particles to 1400 after three months; her HDL returned to the 100s and LDL was 110. The team also added 1gm of niacin daily and after six months her LDL was 129, HDL 111, triglycerides 59, with a particle number of 616.

From the panel, Bhatt agreed on the treatment, but said he would have done so without the additional testing for LDL particles and lipoprotein(a).

Eckel stated that data on Lp(a) is becoming more mature and are demonstrating a relationship between Lp(a)s and coronary events. While there aren’t many guidelines of what to do when patients report with high Lp(a) scores, Eckel said for patients with scores above 30, he tries to lower LDL levels 50% below the initial goal.

Moderator Ballantyne, agreed that Lp(a) scores are being shown in genetic studies to indicate elevated risks among family members and should be examined as indicators.