The New Gold Standard for Lipoprotein Analysis. Advanced Testing for Cardiovascular Risk

The New Gold Standard for Lipoprotein Analysis Advanced Testing for Cardiovascular Risk

Evolution of Lipoprotein Testing The Lipid Panel Total Cholesterol = VLDL + LDL + HDL

Evolution of Lipoprotein Testing The Lipid Panel Total Cholesterol = VLDL + LDL + HDL Friedewald Equation: VLDL = TG/5 Calculated LDL = TC (HDL + TG/5)

Evolution of Lipoprotein Testing The Lipid Panel Total Cholesterol = VLDL + LDL + HDL Friedewald Equation: VLDL = TG/5 Calculated LDL = TC (HDL + TG/5) Direct LDL is Better

Evolution of Lipoprotein Testing The Lipid Panel Total Cholesterol = VLDL + LDL + HDL Friedewald Equation: VLDL = TG/5 Calculated LDL = TC (HDL + TG/5) Direct LDL is Better Consensus Statement of the American Diabetes Assoc. & American College of Cardiology Apo B 100 (est. of non-hdl Particles) is Better Yet

NCEP Guidelines for Cardiovascular Disease NCEP - ATP III 50% of at Risk Individuals are Not Identified

NCEP Guidelines for Cardiovascular Disease NCEP - ATP III 50% of at Risk Individuals are Not Identified 50% of Heart Attack Victims have Normal Cholesterol

NCEP Guidelines for Cardiovascular Disease NCEP - ATP III 50% of at Risk Individuals are Not Identified 50% of Heart Attack Victims have Normal Cholesterol NCEP Identified a Number of New Lipoprotein Risk Factors To Help Assess Those at Risk

NCEP New Lipoprotein Risk Factors RLP (Remnant Lipoprotein) - High in 20% of population - One of the Most Atherogenic Lipoproteins -Skips Oxidation Step in Forming Plaque

NCEP New Lipoprotein Risk Factors RLP (Remnant Lipoprotein) - High in 20% of population - One of the Most Atherogenic Lipoproteins -Skips Oxidation Step in Forming Plaque High in 25% of population - 3-fold Greater Risk of CVD than Buoyant LDL - Penetrates Arterial Endothelial Lining Easily - Less Recognized by LDL Receptors therefore Increases Small Dense LDL Lp(a) - High in 20% of population - Small Particles that are Easily Oxidized - Competes with Plasminogen, Prevents Fibrinolysis

Lp(a) Competes with Plasminogen and Prevents Fibrinolysis Fibrinogen Fibrin Blood Clot (MI, Stroke or DVT)

Lp(a) Competes with Plasminogen and Prevents Fibrinolysis Fibrinogen Plasminogen Fibrin Plasmin Blood Clot (MI, Stroke or DVT) Fibrinolysis

Lp(a) Competes with Plasminogen and Prevents Fibrinolysis Many of the over 40 genetic variations of Lp(a) mimic plasminogen Plasminogen Fibrinogen Lp(a) Fibrin Plasmin Blood Clot (MI, Stroke or DVT) Fibrinolysis

Lipoprotein Particles Apolipoprotein A-1 (HDL) or B-100 (LDL)

Lipoprotein Particles Apolipoprotein A-1 (HDL) or B-100 (LDL) Unesterified Cholesterol Phospholipid

Lipoprotein Particles Apolipoprotein A-1 (HDL) or B-100 (LDL) Cholesterol Ester Triglyceride Unesterified Cholesterol Phospholipid

Atherogenic Particles Size (nm) Density (g/cm 3) 50 1.004 25 1.013 VLDL RLP TG-rich Lipoproteins

Atherogenic Particles Size (nm) Density (g/cm 3) 50 1.004 25 1.013 22 1.023 19 1.044 VLDL RLP Buoyant LDL Dense LDL TG-rich Lipoproteins

Atherogenic Particles Size (nm) Density (g/cm 3) 50 1.004 25 1.013 22 1.023 19 1.044 VLDL RLP Buoyant LDL Dense LDL TG-rich Lipoproteins Mean Endothelial Pore Size

CETP in Cholesterol Metabolism Apo B-100 VLDL Liver Brewer HB et al. Am J Cardiol 2003;92:10K-16K.

CETP in Cholesterol Metabolism Apo B-100 VLDL LPL IDL Liver Brewer HB et al. Am J Cardiol 2003;92:10K-16K.

CETP in Cholesterol Metabolism Apo B-100 VLDL LPL IDL HL LDL 1-2 Liver Brewer HB et al. Am J Cardiol 2003;92:10K-16K.

CETP in Cholesterol Metabolism Apo B-100 VLDL LPL IDL HL LDL 1-2 HL LDL 3-4 Liver Brewer HB et al. Am J Cardiol 2003;92:10K-16K.

CETP in Cholesterol Metabolism Apo B-100 VLDL LPL IDL HL LDL 1-2 HL LDL 3-4 Liver TG s CETP CE Brewer HB et al. Am J Cardiol 2003;92:10K-16K.

CETP in Cholesterol Metabolism Apo B-100 VLDL LPL IDL HL LDL 1-2 HL LDL 3-4 Liver TG s CETP CE Liver Apo A-1 Nascent HDL Brewer HB et al. Am J Cardiol 2003;92:10K-16K.

CETP in Cholesterol Metabolism Apo B-100 VLDL LPL IDL HL LDL 1-2 HL LDL 3-4 Liver TG s CETP CE Liver Apo A-1 HDL Enters Cells & Arterial Intima Nascent HDL Brewer HB et al. Am J Cardiol 2003;92:10K-16K.

CETP in Cholesterol Metabolism Apo B-100 VLDL LPL IDL HL LDL 1-2 HL LDL 3-4 Liver TG s CETP CE Liver Apo A-1 HDL3 LCAT HDL Enters Cells & Arterial Intima Nascent HDL Brewer HB et al. Am J Cardiol 2003;92:10K-16K.

CETP in Cholesterol Metabolism Apo B-100 VLDL LPL IDL HL LDL 1-2 HL LDL 3-4 Liver TG s CETP CE Liver Apo A-1 Reverse Cholesterol Transport HDL2b LCAT HDL3 LCAT HDL Enters Cells & Arterial Intima Nascent HDL Brewer HB et al. Am J Cardiol 2003;92:10K-16K.

Atherosclerotic Plaque Formation ARTERIAL LUMEN HDL REMOVES EXCESS LIPIDS LDL Lp(a) MONOCYTE CELL ARTERIAL INTIMA

Atherosclerotic Plaque Formation ARTERIAL LUMEN HDL REMOVES EXCESS LIPIDS LDL Lp(a) MONOCYTE CELL ARTERIAL INTIMA MACROPHAGE CELL

Atherosclerotic Plaque Formation ARTERIAL LUMEN HDL REMOVES EXCESS LIPIDS LDL Lp(a) MONOCYTE CELL DENSE LDL ARTERIAL INTIMA MACROPHAGE CELL

Atherosclerotic Plaque Formation ARTERIAL LUMEN HDL REMOVES EXCESS LIPIDS LDL Lp(a) MONOCYTE CELL DENSE LDL OXIDIZED LDL ARTERIAL INTIMA MACROPHAGE CELL

Atherosclerotic Plaque Formation ARTERIAL LUMEN HDL REMOVES EXCESS LIPIDS LDL Lp(a) MONOCYTE CELL FOAM CELL DENSE LDL OXIDIZED LDL ARTERIAL INTIMA MACROPHAGE CELL

Atherosclerotic Plaque Formation ARTERIAL LUMEN HDL REMOVES EXCESS LIPIDS FOAM CELLS BUILD PLAQUE LDL Lp(a) MONOCYTE CELL FOAM CELL DENSE LDL OXIDIZED LDL ARTERIAL INTIMA MACROPHAGE CELL

Atherosclerotic Plaque Formation ARTERIAL LUMEN HDL REMOVES EXCESS LIPIDS RLP FOAM CELLS BUILD PLAQUE LDL Lp(a) MONOCYTE CELL FOAM CELL DENSE LDL OXIDIZED LDL ARTERIAL INTIMA MACROPHAGE CELL

Atherosclerotic Plaque Formation INFLAMMATION RUPTURES PLAQUE ARTERIAL LUMEN HDL REMOVES EXCESS LIPIDS RLP FOAM CELLS BUILD PLAQUE LDL Lp(a) MONOCYTE CELL FOAM CELL DENSE LDL OXIDIZED LDL ARTERIAL INTIMA MACROPHAGE CELL

Why Have the LPP Test? Provides a More Complete Risk Answer than the Standard Cholesterol Test

Why Have the LPP Test? Provides a More Complete Risk Answer than the Standard Cholesterol Test LPP Has Three Risk Identifying Components

Why Have the LPP Test? Provides a More Complete Risk Answer than the Standard Cholesterol Test LPP Has Three Risk Identifying Components 1. NCEP s New Lipoprotein Risk Factors

Why Have the LPP Test? Provides a More Complete Risk Answer than the Standard Cholesterol Test LPP Has Three Risk Identifying Components 1. NCEP s New Lipoprotein Risk Factors 2. Lipoprotein Particle Numbers vs. Cholesterol Content 3. Non-Lipid Risk Factors: Lp-PLA 2, CRP, Insulin and Homocysteine

Lipoprotein Particle Profile (LPP ) ) Process Separates by Density using Analytical Ultracentrifugation the CDC s s Gold Standard

Lipoprotein Particle Profile (LPP ) ) Process Separates by Density using Analytical Ultracentrifugation the CDC s s Gold Standard The New Gold Standard - Enhancements

Lipoprotein Particle Profile (LPP ) ) Process Separates by Density using Analytical Ultracentrifugation the CDC s s Gold Standard The New Gold Standard - Enhancements Continuous Gradient Clinically Relevant Lipoprotein Particles are Detected Not the Surrogate Marker Cholesterol

Lipoprotein Particle Measurement Fluorescent Dye a Phospholipid Analog Fluorescent - Hydrophilic End Hydrophobic End

Lipoprotein Particle Measurement Fluorescent Dye a Phospholipid Analog Fluorescent - Hydrophilic End Hydrophobic End When Hydrophobic End Imbeds into the Phospholipid Shell of the Lipoprotein the Hydrophilic End Fluoresces

Separation by Density Centrifuge Tube with Mixture of Serum, Gradient and Dye

Separation by Density Centrifuge Tube with Mixture of Serum, Gradient and Dye Density (g/ml) Separated Lipoproteins Intense Gravitational Force 600,000 G s 1.000 1.006 1.030 1.063 1.100 1.300 VLDL LDL HDL Proteins

LPP Test - Lipoprotein Groups and Subgroups Accurate Densities

LPP Test - Lipoprotein Groups and Subgroups Particle Measurement

LPP Test - Lipoprotein Groups and Subgroups VLDL

LPP Test - Lipoprotein Groups and Subgroups LDL

LPP Test - Lipoprotein Groups and Subgroups Buoyant -Large

LPP Test - Lipoprotein Groups and Subgroups Dense -Small

LPP Test - Lipoprotein Groups and Subgroups HDL

LPP Test - Lipoprotein Groups and Subgroups HDL HDL3 HDL2b

LPP showing NCEP s s New Lipoprotein Risk Factors Healthy Profile Buoyant LDL High HDL 2b Low RLP Atherogenic Profile

LPP showing NCEP s s New Lipoprotein Risk Factors Healthy Profile Atherogenic Profile Buoyant LDL High HDL 2b Low RLP Atherogenic Profile High RLP Dense LDL Low HDL 2b

Lipoprotein Particle Numbers All of These Patients have the Same LDL Cholesterol A B C D 125 mg/dl 125 mg/dl 125 mg/dl 125 mg/dl

Lipoprotein Particle Numbers All of These Patients have the Same LDL Cholesterol A B C D 125 mg/dl 125 mg/dl 125 mg/dl 125 mg/dl LDL Particles with Varying Cholesterol Content Large - Buoyant

Lipoprotein Particle Numbers All of These Patients have the Same LDL Cholesterol A 125 mg/dl B 125 mg/dl C 125 mg/dl D 125 mg/dl LDL Particles with Varying Cholesterol Content TG s & CETP Large - Buoyant Large - Buoyant Depleted

Lipoprotein Particle Numbers All of These Patients have the Same LDL Cholesterol A B C D 125 mg/dl 125 mg/dl 125 mg/dl 125 mg/dl LDL Particles with Varying Cholesterol Content TG s & CETP -TG s & CETP Large - Buoyant Large - Buoyant Depleted Small - Dense Enriched

Lipoprotein Particle Numbers All of These Patients have the Same LDL Cholesterol A B C D 125 mg/dl 125 mg/dl 125 mg/dl 125 mg/dl LDL Particles with Varying Cholesterol Content TG s & CETP -TG s & CETP TG s & CETP Large - Buoyant Large - Buoyant Depleted Small - Dense Enriched Small - Dense Depleted

Lipoprotein Particle Numbers All of These Patients have the Same LDL Cholesterol A B C D 125 mg/dl 125 mg/dl 125 mg/dl 125 mg/dl LDL Particles with Varying Cholesterol Content TG s & CETP -TG s & CETP TG s & CETP Large - Buoyant Large - Buoyant Depleted Small - Dense Enriched Small - Dense Depleted Low Particle Numbers or Apo B-100 Increased Increased High

Lipoprotein Particle Numbers All of These Patients have the Same LDL Cholesterol A B C D 125 mg/dl 125 mg/dl 125 mg/dl 125 mg/dl LDL Particles with Varying Cholesterol Content TG s & CETP -TG s & CETP TG s & CETP Large - Buoyant Large - Buoyant Depleted Small - Dense Enriched Small - Dense Depleted Low Risk Particle Numbers or Apo B-100 Increased Increased High

Cholesterol Depleted Profile High VLDL and TG s

Cholesterol Depleted Profile High VLDL and TG s TG s TG s CETP exchanges cholesterol for triglycerides

Cholesterol Depleted Profile High VLDL and TG s Chemistry 191 LDL 112 HDL 39 No LDL Treatment LPP - CEQ TC 226 LDL 135 HDL 43 Treat LDL TG s TG s CETP exchanges cholesterol for triglycerides

Relevance of Lipoprotein Particle Numbers A Disconnect Exist between Lipoprotein Particle Number and Cholesterol Number 30% of the Population is Cholesterol Depleted 20% of the Population is Cholesterol Enriched The LPP Test is Like Having Apo B-100 Broken Down into Subgroups for a Better Therapeutic Approach

Test Report Page 1 Reference Value

Test Report Page 1 Reference Value Green is Normal Yellow is Borderline Red is High

Test Report Page 1 Reference Value Green is Normal Yellow is Borderline Red is High The Magnitude of the Result is Easy to Judge with Respect to the Reference Value Color Highlighted Numerical Results

Test Report Page 2 Primary Risk Assessment Direct Lipid Panel in Cholesterol Equivalents

Test Report Page 2 Primary Risk Assessment Graph Quick Assessment Direct Lipid Panel in Cholesterol Equivalents

Test Report Page 2 Primary Risk Assessment Graph Quick Assessment Direct Lipid Panel in Cholesterol Equivalents Risk Modification LPP+ includes Lp-PLA 2, C-Reactive Protein, Insulin and Homocysteine

Test Report Page 2 Primary Risk Assessment Graph Quick Assessment Direct Lipid Panel in Cholesterol Equivalents Risk Modification LPP+ includes Lp-PLA 2, C-Reactive Protein, Insulin and Homocysteine Therapeutic Approach Direct Measurement of Lipoprotein Particle Numbers, Lp(a) and LDL Size

Interrelation Between Atherosclerosis and Metabolic Syndrome - Insulin Resistance Six Possible Traits Hypertension Obesity High Glucose

Interrelation Between Atherosclerosis and Metabolic Syndrome - Insulin Resistance Six Possible Traits Hypertension Obesity High Glucose High Triglycerides Small, Dense LDL Low HDL

Interrelation Between Atherosclerosis and Metabolic Syndrome - Insulin Resistance Six Possible Traits Hypertension Metabolic Syndrome Insulin Resistance Obesity High Glucose High Triglycerides Small, Dense LDL Low HDL Atherosclerosis Risk Increases

The Role of CETP and TG s in Metabolic Syndrome Liver Apo B-100 High TG s VLDL Bays H. Expert Rev Cardiovasc Ther 2004;2:89-105.

The Role of CETP and TG s in Metabolic Syndrome Liver Apo B-100 High TG s VLDL TG s CETP CE LDL 1-2 Depleted Bays H. Expert Rev Cardiovasc Ther 2004;2:89-105.

The Role of CETP and TG s in Metabolic Syndrome TG s Liver Apo B-100 High TG s VLDL TG s CETP CE LDL 1-2 Depleted HL Small Dense LDL 3-4 Bays H. Expert Rev Cardiovasc Ther 2004;2:89-105.

The Role of CETP and TG s in Metabolic Syndrome TG s RLP LPL TG s Liver Apo B-100 High TG s VLDL TG s CETP CE LDL 1-2 Depleted HL Small Dense LDL 3-4 Bays H. Expert Rev Cardiovasc Ther 2004;2:89-105.

The Role of CETP and TG s in Metabolic Syndrome TG s RLP LPL TG s Liver Apo B-100 High TG s VLDL TG s CETP CE LDL 1-2 Depleted HL Small Dense LDL 3-4 CE CETP TG s HDL Depleted Bays H. Expert Rev Cardiovasc Ther 2004;2:89-105.

The Role of CETP and TG s in Metabolic Syndrome TG s RLP LPL TG s Liver Apo B-100 High TG s VLDL TG s CETP CE LDL 1-2 Depleted HL Small Dense LDL 3-4 CE CETP HDL Depleted TG s TG s HL Small Dense HDL3 Bays H. Expert Rev Cardiovasc Ther 2004;2:89-105.

Atherogenic Profile with High TG s, Low HDL and Dense LDL. Patient has Metabolic Syndrome High Triglycerides (VLDL) Dense LDL Low HDL

Atherogenic Profile with High TG s, Low HDL and Dense LDL. Patient has Metabolic Syndrome High Triglycerides (VLDL) Dense LDL Three Lipid Traits is a Probable Diagnosis of Metabolic Syndrome Low HDL

Atherogenic Profile with High TG s, Low HDL and Dense LDL. Patient has Metabolic Syndrome High Triglycerides (VLDL) Dense LDL Low HDL Three Lipid Traits is a Probable Diagnosis of Metabolic Syndrome Most Likely the Patient has One or More non-lipid Traits: 1. Hypertension 2. Obesity 3. High glucose

The role of Lp-PLA 2 in plaque formation LUMEN INTIMA

The role of Lp-PLA 2 in plaque formation LUMEN Plaque Formation INTIMA Oxidized LDL Macrophage Foam Cell

The role of Lp-PLA 2 in plaque formation LUMEN INTIMA Oxidized LDL Lp-PLA 2

The role of Lp-PLA 2 in plaque formation LUMEN Lyso-PC OxFA INTIMA Lp-PLA 2 Oxidized LDL

The role of Lp-PLA 2 in plaque formation LUMEN Monocytes Lyso-PC OxFA Adhesion molecules Cytokines INTIMA Lp-PLA 2 Oxidized LDL

The role of Lp-PLA 2 in plaque formation LUMEN Monocytes Lyso-PC OxFA Adhesion molecules Cytokines INTIMA Oxidized LDL Lp-PLA 2 Macrophage

LPP Treatment Strategy

LPP Treatment Strategy 1 Primary Risk Assessment from Direct Lipid Panel with Cholesterol Equivalents

LPP Treatment Strategy 1 Primary Risk Assessment from Direct Lipid Panel with Cholesterol Equivalents 2 Modify Risk Level Using Metabolic Syndrome Traits Lp-PLA 2, CRP and Insulin

LPP Treatment Strategy 1 Primary Risk Assessment from Direct Lipid Panel with Cholesterol Equivalents 2 Modify Risk Level Using Metabolic Syndrome Traits Lp-PLA 2, CRP and Insulin 3 Direct Therapeutic Approach Based on LDL and HDL Subgroup Distributions and Lp(a)

Important Benefits of the LPP Test Identification of the NCEP New Risk Factors

Important Benefits of the LPP Test Identification of the NCEP New Risk Factors Measurement of Lipoprotein Particles Numbers with Lipid Panel in Cholesterol Equivalents

Important Benefits of the LPP Test Identification of the NCEP New Risk Factors Measurement of Lipoprotein Particles Numbers with Lipid Panel in Cholesterol Equivalents Identification of Lipid Metabolic Syndrome Traits

Male Patient on 4 gm EPA & DHA Omega-3 s, adding 10 mg Rosuvastatin for two months and then 600 mg N-acetyl N Cysteine for two weeks 10 mg Rosuvastatin LDL decreased from 152 to 78 (48%) 10 mg Statin

Male Patient on 4 gm EPA & DHA Omega-3 s, adding 10 mg Rosuvastatin for two months and then 600 mg N-acetyl N Cysteine for two weeks 10 mg Rosuvastatin LDL decreased from 152 to 78 (48%) 600 mg NAC 10 mg Statin 600 mg NAC VLDL decreased from 140 to 82 TG s decreased from 182 to 97 (46%) Homocysteine decreased from 10.2 to 6.9

Examples of the Atherogenic Apo C-1 C 1 Enriched HDL and Low Birth Weight Babies (~6 lb vs ~7 lb)* Apo C-1 HDL at d = 1.06 High and Very Buoyant HDL Low TG s, VLDL and RLP

Examples of the Atherogenic Apo C-1 C 1 Enriched HDL and Low Birth Weight Babies (~6 lb vs ~7 lb)* Apo C-1 HDL at d = 1.06 High and Very Buoyant HDL Apo C-1 HDL Characteristics Observed in 1-2% of Specimens Low TG s, VLDL and RLP

Examples of the Atherogenic Apo C-1 C 1 Enriched HDL and Low Birth Weight Babies (~6 lb vs ~7 lb)* Apo C-1 HDL at d = 1.06 Low TG s, VLDL and RLP High and Very Buoyant HDL Apo C-1 HDL Characteristics Observed in 1-2% of Specimens Proinflammatory HDL Associated with Endothelial Dysfunction

Lipoprotein Particle Numbers Therapeutic Guidelines Lipoprotein Therapeutic Statins Niacin Fibrates Estrogens Resins Absorption Omega-3 s Alcohol Life Style Inhibitors EPA & DHA (moderate) Changes (diet & exercise) VLDL (Triglycerides) X X RLP (IDL) X X ** LDL I & II - buoyant ** LDL III - dense ** LDL IV or Lp(a) HDL 2b - buoyant HDL 2a & 3 Therapeutic Beneficial Little or No Effect X Negative Result *These guidelines provide some of the treatment options available to modify lipoprotein particle numbers determined by the LPP TM test. **Spectracell Laboratories observed response to treatment. The National Cholesterol Education Program (NCEP) guidelines provide dosage information on the treatment options.