Non-fasting lipid profiles: implications for lipoprotein testing and

reportingConsensus guideline of the European Atherosclerosis Society (EAS) and

European Federation of Clinical Chemistry and Laboratory Medicine (EFLM)

presenter: Michel Langlois MD,PhD

AZ St.-Jan Bruges & University of Ghent, BelgiumChair of EFLM Task & Finish Group – Laboratory Testing for Dyslipidemia

EFLM webinar

moderator: prof. Dr. Jerzy-Roch Noferleader of the scientific Clinical Chemistry division at the University of Münster.

About Presenter• Professor at Ghent University, Department of Cardiovascular

Diseases• Vice-Director at the laboratory of AZ St-Jan hospital, Bruges• President of the Belgian Atherosclerosis Society• Past-president of the Royal Belgian Society of Laboratory Medicine• Chair of the EFLM-EAS Task and Finish Group on Laboratory

Testing for Dyslipidemia• Member of the EFLM WG-Guidelines• Corresponding member for the EFLM WG-Cardiac Markers and

WG-Congresses and Postgraduate Education

Non-fasting Lipid Profiles: EAS-EFLM Consensus Statement

1. Why has fasting been the standard?

2. Which lipoproteins are atherogenic?

3. Influence of food intake on lipid tests?

4. Non-fasting lipid tests: fit for purpose?

5. Implications & guidelines for laboratories

• Postprandial variation of Triglycerides (TG)

• Calculation of LDL-cholesterol (LDLC)Friedewald equation:LDLC = TC – HDLC – TG/2.2(mmol/l)

TG/5 (mg/dl)

Fasting Lipid Profiles: Why?

Invalid when TG >4.5 mmol/l (400 mg/dl)

• Practical§ Patients§ Healthcare practitioners§ Laboratories

• MedicalDaily average lipid status is nonfasting

Fasting Lipid Profiles: disadvantages

QUESTION 1:

Fasting LDL-C sufficiently estimates dyslipidemia-related risk in all patients?• YES• NO

Non-fasting Lipid Profiles: EAS-EFLM Consensus Statement

1. Why has fasting been the standard?

2. Which lipoproteins are atherogenic?

3. Influence of food intake on lipid tests?

4. Non-fasting lipid tests: fit for purpose?

5. Implications & guidelines for laboratories

Atherogenic lipoproteins

• Remnant particles

• LDL-particles

• Lipoprotein(a)

B

B. NordestgaardA. VarboThe Lancet 2014; 384:626-635

A.Varbo et al. Copenhagen General Population Study, Copenhagen City Heart Study, & Copenhagen Ischemic Heart Disease Study. J Am Coll Cardiol 2013;61:427-36.

Remnant cholesterol is a direct, causal CVD risk factor

LDL-particles

Low LDL-C; underestimated risk

Misleading LDL-C

Atherogenic Dyslipidemia in Diabetes and the Metabolic Syndrome

Lp(a)

LDL particle + apo(a)

2 to >40 KIV2repeats

HDL

VLDL

IDL

Chylo-microns

Lp(a)

LDL

LDLCHDLC

ChylomicronRemnants

Den

sity

(g/m

l)

TC

Size

HDL

VLDL

IDL

Chylo-microns

Lp(a)

LDL

LDLCHDLC ‘Remnant-C’

Non-HDLC

ChylomicronRemnants

ApoB ApoA-I

Den

sity

(g/m

l)

TC

Size

Non-fasting Lipid Profiles: EAS-EFLM Consensus Statement

1. Why has fasting been the standard?

2. Which lipoproteins are atherogenic?

3. Influence of food intake on lipid tests?

4. Non-fasting lipid tests: fit for purpose?

5. Implications & guidelines for laboratories

QUESTION 2:

Food intake significantly influences lipid tests ?

• YES

• NO

A. Langsted et al. Circulation 2008;118:2047-2056.

Non-fasting Lipid Profiles: EAS-EFLM Consensus Statement

1. Why has fasting been the standard?

2. Which lipoproteins are atherogenic?

3. Influence of food intake on lipid tests?

4. Non-fasting lipid tests: fit for purpose?

5. Implications & guidelines for laboratories

Nordestgaard et al. EAS EFLM joint Consensus Panel. Eur Heart J 2016

Population-based studies N >300 000 non-fasting individuals

Statin trials N= 43 000 non-fasting individuals

Tromsø Heart Study Heart Protection Study

Norwegian National Health Service Anglo-Scandinavian Cardiac Outcomes Trial—Lipid Lowering Arm

British Population Studies Study of the Effectiveness of Additional Reductions in Cholesterol and Homocysteine

European Prospective Investigation of Cancer–Norfolk

Northwick Park Heart StudyApolipoprotein-related Mortality RiskCopenhagen City Heart StudyWomen's Health StudyNurses' Health StudyPhysicians' Health Study

National Health and Nutrition Examination Survey III

Circulatory Risk in Communities StudyCopenhagen General Population Study

INTERHEART study

Nordestgaard et al. EAS EFLM joint Consensus Panel. Eur Heart J 2016

• Potential for risk misclassification in hypertriglyceridemic samples!

Abbott Beckman Olympus Roche Siemens Ortho

1.3

1.2

1.1

1.0

0.9

0.8

0.7

0.6

Langlois M et al. The EAS-EFLM Collaborative Project. Atherosclerosis 2014; 233:83-90

1.08CDC Reference Laboratory,Rotterdam

EQA survey (n=197 labs) of hypertriglyceridemic serum (~7 mmol/l)

Risk cutpoint

In red: SCORE>5 % and LDL-C ³ 2.50 mmol/L: start statin therapy immediately In green: SCORE>5 % and LDL-C <2.50 mmol/L: not applicable for statin therapy.

Clinical simulation: effect of direct LDL-C method variation on treatment

= TC - HDLC

A.Varbo et al. Copenhagen General Population Study. J Am Coll Cardiol 2013;61:427-36.

Non-fasting non-HDLC includes ‘remnant-cholesterol’

Abbott Beckman Olympus Roche Siemens Ortho

5.3

5.1

4.9

4.7

4.5

4.3

Langlois M et al. The EAS-EFLM Collaborative Project. Atherosclerosis 2014; 233:83-90

EQA survey (n=197 labs) of hypertriglyceridemic serum

In cases with TG 200-400 mg/dL(2.3-4.5 mmol/L)

De, Denka; Ky, Kyowa; Ro, Roche; Sr, Serotec; Sk, Sekisui, Sy, Sysmex; Um, UMA; Wa, Wako.

van Deventer HE et al. Clin Chem 2011;57:490-501

Misclassification of CVD risk(A) direct LDLC(B) calculated LDLC(C) non–HDLCcompared to Reference Method

TG

CC CTG

C

VLDL VLDL remnant

Small dense LDL

Large LDL

apoB apoB apoB apoB

ApoB : marker of atherogenic particle number

TG: triglycerides C: cholesterol

B B B B

<1%

<10%

~90%

ApoB48

ApoB100

Non-fasting apoB

Apo B 0.6 g/l Apo B 1.2 g/l

LDL cholesterol 100 mg/dl

Triglycerides 120 mg/dl

LDL cholesterol 100 mg/dl

Triglycerides 300 mg/dl

B B B

B B B

B B B B

B

B B B B

B

ApoB vs. LDLC

BB

I. van den Broek et al. Clin Chem 2016;62:188-97.

ApoB assays: traceable to WHO/IFCC reference material

NTG: normotriglyceridemia, HTG: hypertriglyceridemia, ITA: immunoturbidimetric assay

• Non-HDLC§ Calculated as TC – HDLC at no additional cost§ Includes ‘remnant-C’§ Not influenced by TG variability§ HDLC measurement errors!

• ApoB§ Simple, automated assay§ Single, well-defined measurand§ International standard SP3-08 (WHO / IFCC)§ LDL-particle number count

Non-fasting lipoprotein markers beyond LDLC

Comparison of 26 lipid fractions as predictors of first-ever cardiovascular events in apparently healthy women. Data are shown for the top versus bottom quintile of each lipid fraction.

The Lancet 2014;384:607 - 617

Paul M Ridker LDL cholesterol: controversies and future therapeutic directions

Relative Risk Ratios (RRR) for LDLC, non-HDLC, and apoBfrom 12 independent epidemiological studies

Sniderman A et al. Circ Cardiovasc Qual Outcomes 2011;4:337-345

LDL-C 1.25 (1.18-1.33) non-HDL-C 1.34 (1.24-1.44) ApoB 1.43 (1.35-1.51)

Coronary heart disease (CHD) risk among 13 595 women with LDLC < Median (120 mg/dl)

S.Mora et al. Women’s Health Study. Circulation 2014;129:553-61

Copyright © 2014 American Medical Association. All rights reserved.

From: Association of LDL Cholesterol, Non–HDL Cholesterol, and Apolipoprotein B Levels With Risk of Cardiovascular Events Among Patients Treated With Statins: Meta-analysis of 8 Trials (N=38 153)

Boekholdt SM et al. JAMA. 2012;307:1302-1309.

Hazard ratios (HRs) and 95% CIs for risk of major cardiovascular events for 4 categories of statin-treated patients, based on whether or not they reached the LDL-C target of 100 mg/dL and the non–HDL-C target of 130 mg/dL. HRs were adjusted for sex, age, smoking, diabetes, systolic blood pressure, and trial.

Jepsen AK et al. Clin Chem 2016;62:593-604

Remnant cholesterol explains part of residual risk of mortalityin 5414 patients with ischemic heart disease

“The good,

the bad,

and the ugly”

Non-fasting lipid profile

Non-fasting Lipid Profiles: EAS-EFLM Consensus Statement

1. Why has fasting been the standard?

2. Which lipoproteins are atherogenic?

3. Influence of food intake on lipid tests?

4. Non-fasting lipid tests: fit for purpose?

5. Implications & guidelines for laboratories

QUESTION 3:

Fasting lipid tests are obsolete and should not be used anymore?

• YES

• NO

Key recommendations

Fasting is not routinely required for a lipid profile

At nonfasting TG >4.5mmol/L (>400mg/dL), fasting sampling should be considered

Laboratory reports should flag abnormal concentrations based on desirable cutpoints

Life-threatening or extremely high concentrations should trigger lipid clinic referral

Nordestgaard et al. EAS EFLM joint Consensus Panel. Eur Heart J 2016

EAS-EFLM Consensus GuidelinePublished in Eur Heart J 2016 and Clin Chem 2016

Non-fasting In most patients, including:

· Initial lipid profile testing in any patient

· For CVD risk assessment

· Follow-up of cholesterol-lowering therapy

· In children

· If preferred by the patient

· In diabetic patients (due to hypoglycemic risk)

· In elderly

Fasting Rarely, but fasting can be used if:

· Nonfasting TG >5 mmol/L (>400 mg/dL)

· Diagnosis and follow-up of high TG known in lipid clinic

· Other tests that require fasting, e.g., glycemia

When to use non-fasting and fasting lipid tests?

Nordestgaard et al. EAS EFLM joint Consensus Panel. Eur Heart J 2016

Risk cutpoints Units

mmol/L mg/dL

Triglycerides Fasting

Nonfasting

≥1.7

≥2

≥150

≥175

Total cholesterol ≥5 ≥190

LDL cholesterol ≥3 ≥115

Non-HDL cholesterol Fasting

Nonfasting

≥3.8

≥3.9

≥145

≥150

Lipoprotein(a) ≥50

HDL cholesterol ≤1 ≤40

g/L mg/dL

Apolipoprotein B ≥1 ≥100

Apolipoprotein A1 ≤1.2 ≤120

=LDL-C + TG/5

Risk

SCORE (%)

LDL-C

mg/dl (mmol/l)

Non-HDL-C *

mg/dl (mmol/l)

ApoB *

mg/dl (g/l)

Very high (≥10) < 70 (1.8) < 100 (2.6) < 80 (0.8)

High (5 - <10) < 100 (2.5) < 130 (3.3) < 100 (1.0)

Moderate (1 - <5) < 115 (3.0) < 145 (3.8)

*Secondary targets in patients with combined dyslipidemia, metabolicsyndrome, type 2 diabetes, or chronic kidney disease.

Primary and secondary targets of therapy

Catapano A et al. ESC/EAS Guidelines for Dyslipidemia Management. Atherosclerosis 2011;217:3-46

Definition of hypertriglyceridemia by EAS Consensus

• Mild-to-Moderate§ 175 - 880 mg/dl (2 - 10 mmol/l)§ non-HDLC or apoB secondary target

• Severe§ >880 mg/dl (> 10 mmol/l)§ Prevention of pancreatitis

Hegele RA et al. Lancet Diabetes Endocrinol 2014;2:655-66.

Life-threatening

concentrations

Refer patient to lipid specialist to rule out

TG >10 mmol/L

>880 mg/dL

Chylomicronemia syndrome:

high risk of acute pancreatitis

LDL-C >5 mmol/L

>190 mg/dL

Heterozygous Familial Hypercholesterolemia (FH):

high CVD risk

LDL-C >13 mmol/L

>500 mg/dL

Homozygous Familial Hypercholesterolemia (FH):

very high CVD risk

Lp(a) >150 mg/dL Very high risk of myocardial infarction and

aortic valve stenosis

“Alarm” concentration flagging and reporting

Nordestgaard et al. EAS EFLM joint Consensus Panel. Eur Heart J 2016

® Family cascade screening

Dutch Lipid Clinical Network Criteria Score

Family historyFirst-degree relative with premature coronary and/or vascular disease (men <55 yrs, women <60 yrs) OR with LDL-C >95th percentile 1

First-degree relative with tendinous xanthomata and/or arcus cornealisOR Children <18 yrs with LDL-C >95th percentile 2

Clinical historyPremature coronary artery disease (men <55 yrs, women <60 yrs) 2Premature cerebral or peripheral vascular disease (men <55 yrs, women <60 yrs) 1Physical examinationTendinous xanthomata 6Arcus cornealis before 45 yrs 4Causative mutation in LDL-R, APOB or PCSK9 genes 8LDL-cholesterol ≥8.5 mmol/L (330 mg/dL) 8

6.5–8.4 mmol/L (250–329 mg/dL) 55.0–6.4 mmol/L (190–249 mg/dL) 34.0–4.9 mmol/L (155–189 mg/dL) 1

Diagnosis Total score

Definite FH >8Probable FH 6-8Possible FH 3-5Unlikely FH <3

National Societies for cardiology, endocrinology, atherosclerosis, pediatrics, clinical chemistry, general practice etc.

Key university hospitals and reference centers

National Implementation Strategies

Journalists and key medias disseminate the story that fasting is no longer routinely required for lipid testing

Clinical chemistry laboratories no longer require fasting for lipid testing and use desirable concentration cutpoints for lipid test reporting and flagging

From EFLM: Michel Langlois (Belgium; EFLM co-chair)Hannsjörg Baum (Germany), Christa Cobbaert (The Netherlands), Kari Pulkki (Finland), Grazyna Sypniewska (Poland)From EAS: Børge Nordestgaard (Denmark; EAS co-chair)Jan Borén (Sweden), Olivier Descamps (Belgium), Arnold von Eckardstein (Switzerland), Olov Wiklund (Sweden)Invited expertsEric Bruckert (France), John Chapman (France), Pia Kamstrup (Denmark), Genovefa Kolovou (Greece), Florian Kronenberg (Austria), Anne Langsted (Denmark), Samia Mora (USA), Alan Remaley (USA), Nader Rifai (USA), Emilio Ros (Spain), Gerald Watts ( Australia)

EAS-EFLM Consensus Panelestablished in 2014