REFINING RISK ASSESSMENT IN DIABETIC DYSLIPIDEMIA AFTER ACHIEVING LDL GOALS


Om P. Ganda, M.D., Harvard Medical School, Boston, MA, USA

The current guidelines for lipid management emphasize LDL-cholesterol(LDL-C) as the primary target for high-risk individuals, such as those with type 2 diabetes, with or without prior CVD. Moreover, the recently completed ACCORD- LIPID and AIM-HIGH trials provide a stronger rationale for the pivotal role of intensive LDL reduction in reducing cardiovascular events. However, it is clear that LDL-C is a poor surrogate for LDL particle number, particularly in patients with altered LDL composition, due to triglyceride-rich lipoproteins, such as those with insulin resistance, metabolic syndrome, and type 2 diabetes. The direct measurement of LDL particle number or size is not practical due to methodology and cost considerations. A suggested alternate target in patients with hypertriglyceridemia is non-HDL –cholesterol(non-HDL-C),after attainment of LDL-C goal. However, there is now evidence that even non-HDL-C is an inadequate approximation of the LDL particle number in such patients. This presentation will present data that supports the measuement of apolipipoprotein-B(apo-B) as a more accurate reflection of LDL particle number and an easily adaptable parameter in practice. While achieving the LDL-C target is the primary goal, this should be followed by both non-HDL-C and apo-B in those with hypertriglyceridemia, rather than relying on either alone in such patients. In our data base at Joslin Clinic, we have found up to 37 % discordance between currently recommended non-HDL-C and Apo-B goals. Our data suggest need for prospective studies to compare the relative merits of non-HDL-C and Apo-B in the assessment of cardiovascular risk.