Katsuyuki Nakajima, PhD. Member of JCCLS International Committee

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1 Katsuyuki Nakajima, PhD Member of JCCLS International Committee Visiting Professor and Scientist Tufts University, Boston, MA & Framingham Offspring Study, Framingham, MA August 20 th, 2011, Tokyo

2 Framingham Study is a original model of Japanese Health Check-up system in USA The Framingham Heart Study has first proposed the concept of risk factors and developed risk scores for cardiovascular disease, congestive heart failure, coronary heart disease, diabetes, stroke, and atrial fibrillation*.

4 Framingham Heart Study and Framingham Offspring Study - Framingham, MA 25 miles west of Boston, heart study started in 1950 in about 5,000 men and women to identify heart disease risk factors (ages years). - Factors identified: age, gender, elevated total cholesterol, low HDL C, elevated systolic blood pressure, diabetes, and smoking. - Emerging independent risk factors include: remnant lipoprotein C > 10 mg/dl, small dense LDL C > 40 mg/dl, Lp(a) > 30 mg/dl, adiponectin < 7.0 ug/ml, hscrp, > 2.0 mg/l and family history of heart disease < 60 y. - Framingham Offspring Study subjects are the offspring and their spouses of the original cohort (begun in 1976, also about 5,000). - The Framingham Heart Study has developed risk scores for cardiovascular disease, congestive heart failure, coronary heart disease, diabetes, stroke, and atrial fibrillation*. *

Cholesterol-Carrying Lipoproteins Particle Density, g/ml 0.95 1.006 1.02 1.06 1.10 1.

LDL (increased small dense LDL), and Lp(a), and decreased HDL (decreased large alpha 1 HDL) 5 10 20 40 60 80 1000 Particle Size - Diameter, nm

9 Cholesterol-Carrying Lipoproteins Particle Density, g/ml HDL 3 HDL 2 LDL IDL Lp(a) VLDL Remnants VLDL VLDL VLDL Chylomicron Remnants Chylomicron Heart disease patients often have elevated remnants, LDL (increased small dense LDL), and Lp(a), and decreased HDL (decreased large alpha 1 HDL) Particle Size - Diameter, nm Genest et al Circulation 1992;85:2025 Campos et al, ATVB 1992; 12:187 Schaefer et al JAMA 1994;59:32, McNamara et al Atherosclerosis 2001;154:229 Asztalos et al ATVB 2004;24:2181 Ai et al Clin Chem 2010; 56:

10 The Development of Direct LDL-C FDA for the approval of Statin has requested to develop the kits to measure LDL-C directly to the diagnostic companies late 1980, not just calculated shadow. No USA and EU diagnostic companies have succeeded to develop better Direct LDL-C assay than Japanese ones.

11 Lipoprotein Disorders in Premature CHD Families Familial Lipoprotein (a) Excess: 19% Familial Dyslipidemia (High TG, Low HDL): 15% Familial Combined Hyperlipidemia: 14% Familial Hypoalphalipoproteinemia: 4% Familial Hypercholesterolemia: 1% (use of 10 th and 90 th percentile cutpoints from Framingham) Genest JJ, Martin-Munley S, McNamara JR, Ordovas JM, Jenner J, Myers R, Wilson PW, Schaefer EJ. Circulation 85: , 1992.

12 Framingham Offspring Study Assessment Cycle 6 (n=3,188) Miller WG, Myers GL, Sakurabayashi I et al. Seven direct methods for measuring HDL and LDL cholesterol compared with ultracentrifugation referen 1,335 male controls (mean age 58), 173 male CHD cases 1,606 female controls (mean age 58), 74 female CHD cases Total cholesterol, triglyceride, HDL C measured after overnight fast, HDL C measured after precipitation of apob containing lipoproteins by *dextran sulfate Mg 2+ and LDL C calculated using the Friedewald formula. Direct LDL C and direct HDL C measured on plasma stored at -80 degrees C and never thawed using kits obtained from one of the Japanese manufacturers evaluated in Miller et al paper. *Warnick GR, Benderson J, Albers JJ et al Clin Chem 1982;28: Miller MillerWG, Myers GL, Sakurabayashi I et al. Clin Chem 2010;56(6): Miller WG, Myers GL, Sakurabayashi I et al. Seven direct methods for m.

13 Friedewald Equation VLDL-C = Triglycerids/5 LDL-C= Total Cholesterol - (HDL-C + VLDL-C) Friedewald WT, Levy RI, Fredrickson DS. Estimation of the concentration of low-density lipoprotein cholesterol in plasma, without use of the preparative ultracentrifuge. Clin. Chem. 1972; 18:

14 Direct HDL C vs Dextran HDL C Full Sample Otokozawa S, Ai M, Asztalos BF, White CC, Demissie-Banjaw S, Cupples LA, Nakajima K, Wilson PWF, Schaefer EJ. Atherosclerosis 2010; 213:

15 Direct HDL C versus Dextran HDL C - Healthy Sample Otokozawa S, Ai M, Asztalos BF, White CC, Demissie-Banjaw S, Cupples LA, Nakajima K, Wilson PWF, Schaefer EJ. Atherosclerosis 2010; 213:

16 HDL C % Bias (Direct HDL C Dextran HDL/ Dextran HDL Normal Sample Otokozawa S, Ai M, Asztalos BF, White CC, Demissie-Banjaw S, Cupples LA, Nakajima K, Wilson PWF, Schaefer EJ. Atherosclerosis 2010; 213:

17 HDL C % Bias Remaining Sample Otokozawa S, Ai M, Asztalos BF, White CC, Demissie-Banjaw S, Cupples LA, Nakajima K, Wilson PWF, Schaefer EJ. Atherosclerosis 2010; 213:

18 HDL C % Bias versus Triglyceride Normal Sample Otokozawa S, Ai M, Asztalos BF, White CC, Demissie-Banjaw S, Cupples LA, Nakajima K, Wilson PWF, Schaefer EJ. Atherosclerosis 2010; 213:

19 HDL C % Bias versus Triglyceride Remaining Sample Otokozawa S, Ai M, Asztalos BF, White CC, Demissie-Banjaw S, Cupples LA, Nakajima K, Wilson PWF, Schaefer EJ. Atherosclerosis 2010; 213:

20 Conclusions for HDL C In a study of 3,188 men and women in the Framingham Offdspring Study Direct HDL cholesterol measurements correlated very well with HDL C measured by dextran-mg2+ (r 2 of 0.94, p<0.0001). Biases of > 10% for Direct HDL C vs. dextran HDL C were present in 8.5% of samples. In normal subjects (n=2,082) the slope of the bias between Direct HDL C and Dextran HDL C was (p=0.0467), while in the remaining subjects (those with heart disease, diabetes, or on lipid modifying agents, n=1,106) the slope of this bias was (p<0.0001). In normal subjects the slope of the bias versus triglyceride levels was (p<0.0001), while in the remaining subjects it was (p<0.0001).

21 Direct LDL C versus Calculated LDL C Full Sample Otokozawa S, Ai M, Asztalos BF, White CC, Demissie-Banjaw S, Cupples LA, Nakajima K, Wilson PWF, Schaefer EJ. Atherosclerosis 2010; 213:

22 Direct LDL C versus Calculated LDL C Healthy Sample Otokozawa S, Ai M, Asztalos BF, White CC, Demissie-Banjaw S, Cupples LA, Nakajima K, Wilson PWF, Schaefer EJ. Atherosclerosis 2010; 213:

23 LDL % Bias (Direct LDL Calculated LDL/Calculated LDL) Normal Sample Otokozawa S, Ai M, Asztalos BF, White CC, Demissie-Banjaw S, Cupples LA, Nakajima K, Wilson PWF, Schaefer EJ. Atherosclerosis 2010; 213:

24 LDL C % Bias - Remaining Sample Otokozawa S, Ai M, Asztalos BF, White CC, Demissie-Banjaw S, Cupples LA, Nakajima K, Wilson PWF, Schaefer EJ. Atherosclerosis 2010; 213:

25 LDL C % Bias versus Triglyceride Normal Sample Otokozawa S, Ai M, Asztalos BF, White CC, Demissie-Banjaw S, Cupples LA, Nakajima K, Wilson PWF, Schaefer EJ. Atherosclerosis 2010; 213:

26 LDL C % Bias versus Triglyceride Remaining Sample Otokozawa S, Ai M, Asztalos BF, White CC, Demissie-Banjaw S, Cupples LA, Nakajima K, Wilson PWF, Schaefer EJ. Atherosclerosis 2010; 213:

27 Conclusions for LDL C In a study of 3,188 men and women in the Framingham Offspring Study Direct LDL cholesterol measurements correlated very well with calculated LDL C (r 2 of 0.95, p<0.0001). In normal subjects (n=2,082) the slope of the bias between Direct LDL C and calculated LDL C was (p<0.0001), while in the remaining subjects (those with heart disease, diabetes, or on lipid modifying agents, n=1,106) the slope of this bias was (p<0.0001). In normal subjects the slope of the bias versus triglyceride levels was (p<0.001), while in the remaining subjects it was (p<0.0001).

28 Overall Conclusions-1 In a study of 3,188 men and women, of whom 2,082 were normal and 1,106 had heart disease, diabetes, or were on lipid modifying agents (mainly statins) Direct LDL and HDL cholesterol measurements correlated very well with Calculated LDL C and Dextran-Mg 2+ HDL C (both about r 2 of (p<0.0001), with similar absolute values. Biases of > 10% were present in 8.5% of samples for HLDL C, while for LDL C this value was 7.7%. The Direct HDL C assay overestimated values in subjects with low HDL C and underestimated values in subjects with high HDL as compared to the Dextran method, especially in abnormal subjects. The same finding was true with regard to subjects with low or high triglyceride levels. The Direct LDL C assay overestimated values in subjects with low LDL C and underestimated these values in subjects with high LDL C as compared to Calculated LDL C, especially in abnormal subjects. The Direct LDL C assay performs well in normal subjects, but overestimates values in subjects with high triglycerides. Otokozawa S, Ai M, Asztalos BF, White CC, Demissie-Banjaw S, Cupples LA, Nakajima K, Wilson PWF, Schaefer EJ. Atherosclerosis 2010; 213:

29 Overall Conclusions-2 The Direct HDL C assay serves as a very reasonable guide for the assessment of HDL C in the general population as well as in abnormal subjects. However in subjects with very low HDL C or very high HDL C levels or very high triglyceride levels, the HDL C value may need to be verified with alternative methods such as ultracentrifugation, HPLC, or FPLC. For the assessment of LDL C levels in general the Friedewald calculation serves as a reasonable guide to levels of LDL C. Moreover one can calculate non-hdl C (total cholesterol HDL C) which serves a better guide for CHD risk than LDL C. However In subjects with very low or very high LDL C values, or with non-fasting samples or triglyceride levels > 400 mg/dl, the levels should be verified with the direct method or with alternative methods such as ultracentrifugation, HPLC, or FPLC. Otokozawa S, Ai M, Asztalos BF, White CC, Demissie-Banjaw S, Cupples LA, Nakajima K, Wilson PWF, Schaefer EJ. Atherosclerosis 2010; 213:

30 New Direction of Direct LDL-C More large clinical trials like Framingham Heart study using Direct LDL-C assay kits for the detection of clinical significance need to be done as a kind of phase 4 study of an approved drug when newly improved Direct LDL-C kits are developed. Technological discrepancy which is now discussed at the standardization meeting and clinical discrepancy do not always mean the same.

32 Thank you very much for your attention

2.5% of all deaths globally each year. 7th leading cause of death by % of people with diabetes live in low and middle income countries

2.5% of all deaths globally each year. 7th leading cause of death by % of people with diabetes live in low and middle income countries Lipid Disorders in Diabetes (Diabetic Dyslipidemia) Khosrow Adeli PhD, FCACB, DABCC Head and Professor, Clinical Biochemistry, The Hospital for Sick Children, University it of Toronto Diabetes A Global