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As a physician whose focus is helping patients live longer while preserving quality of life, vascular disease must be the top preventive focus. Cardiovascular disease and Neurovascular disease are the #1 and #3 causes of disability and death in the United States.
In my previous blog, blood pressure optimization was discussed. Other major components of vascular risk include lipids, glucose control, tobacco use, diet, and exercise. This blog will focus on lipids.
Would you be surprised to know that medical students and residents are still being taught lipid management using outdated approaches? What do you know of ApoB and Lp(a)? If these terms are unknown to you, please read onward and learn!
What is Lipoprotein (a)?
Lipoprotein (a) is a substance in your blood stream that can carry lipids or fatty particles(so is LDL, HDL, VLDL). Both Lp(a) and LDL cholesterol contain 1 molecule of Apolipoprotein B, which is the particle that is capable of causing atherosclerosis. However, when Lp(a) is present in higher amounts, it allows Apo B to be more harmful and generates vascular disease, possibly up to 3-5 fold.
Lp(a) is a test you only need once (until we have drugs to directly treat this), as it is a genetic variant. Up to 20% of the population has this – and if you do, your lipid goals (measured by ApoB) need to be managed more carefully and at a lower target to avoid or decrease the risk of vascular disease.
This article has an image which shows the relationship.
It may be a major factor in individuals who don’t have huge vascular risk factors whose lipids are not that bad – but end up having unexpectedly early or severe vascular disease. This article also details Lp(a)
Why not just stick with a standard lipid panel?
The issue is discordance – up to 20% of individuals who are told their lipids are fine will be misinformed, and a similar number who are told they need treatment, may not. This is not even addressing the issue of Lp(a) – just on the ApoB test which determines the number of atherogenic particles.
What are the treatment recommendations?
The recommendations aren’t meant to confuse, but they are complicated. Ultimately, if an individual has a high ApoB, especially if there is also an abnormal Lp(a), vascular disease is gradually forming. It is somewhat illogical to be seen by your doctor in January, and by the guidelines, be told no lipid treatment is needed. Then in February, this individual has a heart attack or stroke, now with harm occurring, and at that moment, they now require aggressive lipid management.
My perspective is an approach of long-term management of ApoB at a level unlikely to lead to vascular disease. Other risks still need to be managed. In general, having a long term ApoB around 70 mg/dL, or if Lp(a) positive then around 50 mg/dL, is expected to avoid new lipid related vascular disease from forming in most individuals.
A great series from one of the best experts in lipids is available here
Short story on lipids – measure an Lp(a) one time only, measure and track your ApoB. Seek professional input to achieve a level that makes it unlikely to have a heart attack, ischemic stroke or develop peripheral vascular disease.
Treatment options include multiple natural substances, which act on many of the same pathways as the prescription medications. Statins, ezetimibe, bempedoic acid and PCSK9 injectable agents are the most commonly used drugs to achieve goals. When consulting with Dr. Fraser, you can access the full range of treatment options, including supplements. Major abnormalities in ApoB, especially when there is also an elevated Lp(a) will usually require prescription medications.
Disclaimer:
This blog provides general education only and should not be used to diagnose or replace the advice of a qualified medical professional. This content is not intended to be a substitute for consultation with a qualified and licensed physician or other medical provider. Readers should consult a medical professional for advice, diagnosis and treatment relating to their individual case.
