Potential Effect of an Apoprotein B‐based Algorithm on Management of New Patients with Hypertriglyceridemia Referred to a Specialty Lipid Clinic

Abstract

Background: In patients with hypertriglyceridemia, non-high density lipoprotein cholesterol (nonHDL-C) is a targeted goal. However, apoprotein B100 (apoB) may be superior in predicting cardiovascular risk so we assessed the utility of an apoB-based. Methods: New patients (n=125) who had both apoB and standard lipids measured on the same day were included and we determined the concordances of having achieved goal lipid levels based upon proposed apoB versus nonHDL-C (ATP III) targets in patients with elevated TG (>150 mg·dl −1 ) levels.Results: Although apoB was correlated with nonHDL-C (r = 0.47, p<0.001), the tests had only a fair level of agreement when categorizing the percentage of patients achieving lipid goals for their degree of cardiovascular risk (κ = 0.22). Among patients with an elevation in nonHDL-C above ATP III goals, between 12-42% had achieved target apoB. On the contrary, between 44-50% of patients were found to be at nonHDL-C but not apoB target. The results were not substantively altered if the analyses were confined to patients with TG values between 200-499 mg·dl −1 , rather than all patients with TG levels >150 mg·dl −1 , as specifically outlined in ATP III guidelines. In total, >50% of all subjects would have been treated either more or less aggressively following an apoB-based therapeutic algorithm. Conclusions: Our findings confirm that the majority of patients referred with hypertriglyceridemia would be managed differently by following an apoB-based treatment algorithm compared to ATP III guidelines. Although many patients would be candidates for more intense therapy, many would be treated less aggressively.

Potential effects on clinical management of treatment algorithms on the basis of apolipoprotein-B/A-1 and total/high-density lipoprotein-cholesterol ratios

“…However, we have shown, 10 as have previous larger studies, similar discordances between apoB and non-HDL-C. 8,9 One would expect that the ratios would be at least, if not more, discordant in this regard as we observed. Among higher-risk people, a comparatively small percentage of patients were at lipid goals upon referral.…”

“…One important reason is the paucity of data demonstrating that ratio-based strategies could meaningfully alter practice patterns. Although we and others [8][9][10] have illustrated discordance between goal attainments using apoB versus traditional lipoproteins, this has not been reported for non-HDL-C versus either ratio as far as we are aware. As such, we aimed to assess the potential effects on our subsequent practice of apoB/A-R and TC/HDL-R algorithms, stipulating the fact that it is appropriate to do so because the ratios are superior risk predictors.…”