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Cholesterol Testing Not Enough for Some

Test for Protein Called ApoB Better Measure of Heart Attack, Stroke Risk
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WebMD Health News

March 27, 2008 -- People at high risk for heart attacks and strokes may need even more aggressive cholesterol control than is currently recommended, experts now say.

In a joint statement released Thursday by the American Diabetes Association (ADA) and the American College of Cardiology (ACC), the experts concluded that measuring LDL, or bad, cholesterol may no longer be the best measure of heart health in these patients.

The panel found that once LDL cholesterol is lowered to recommended levels in high-risk patients, testing for the protein ApoB may more accurately identify those still at risk for cardiovascular events.

If ApoB levels are high, patients may need more aggressive lifestyle interventions or larger doses of lipid-lowering statin drugs, even if LDL cholesterol levels are within normal range, the panel concluded.

"LDL measurement is still very important," ADA Vice President of Clinical Affairs Sue Kirkman, MD, tells WebMD. "But for high-risk people who are on statin therapy it may not be enough to get LDL down below 100 or even 70."

LDL and ApoB

Achieving an LDL of below 100 milligrams/deciliter is now widely recommended for patients with two or more risk factors for heart disease and for those with diabetes but no other major heart disease risk factors.

Guidelines call for a target LDL at or below 70 for patients with established heart disease or diabetes with additional risk factors for heart disease.

These risk factors include high blood pressure, tobacco use, and family history of heart disease.

While aggressive cholesterol treatment has contributed to reductions in heart attacks and strokes, these events are still common among high-risk patients who reach the target goals, Kirkman says. This could occur if other cholesterol particles that contribute to risk are still elevated.

ApoB is a molecule that is present in all the cholesterol particles that significantly contribute to the development of atherosclerosis (also known as plaque or hardening of the arteries).  The hope is that measuring ApoB will help patients and their doctors better gauge actual risk because ApoB will be a more accurate measure of the total number of all artery-clogging particles (not just LDL).  There is growing evidence that ApoB levels are a better indicator of heart risk than total cholesterol or LDL.

For this reason, the joint panel recommends a target ApoB level of less than 90 for high-risk patients without established heart disease and less than 80 for the highest-risk patients with heart disease or with diabetes and other cardiovascular risk factors.

Statins and Lifestyle

The report could lead to more aggressive treatment of high-risk patients with lipid-lowering statins, but the panel concluded that more research is needed to confirm the benefits of this approach.

The group also called for public health initiatives aimed at promoting lifestyle changes that reduce cardiovascular risk.

Kirkman says patients and their doctors often focus on drug treatments, forgetting that lifestyle changes can also have a big impact on risk.

"It is important to remember that lifestyle is a big part of this," Kirkman says. "Getting patients to improve their diets, stop smoking, and exercise are all critical. It isn't all about drugs."

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Your total cholesterol level is in the Desirable range, but your level of "bad" LDL cholesterol is Very High. This may mean that your level of high-density lipoprotein (HDL), or "good" cholesterol, is too low. It is best to have a high level of "good" HDL and a low level of "bad" LDL because the HDL helps keep your LDL level in check. Ask your doctor for your HDL level. If your HDL is low, increasing your physical activity can increase it, which may help reduce your LDL level.

Your total cholesterol level is Borderline High, but fortunately your level of "bad" LDL cholesterol is optimal. This could mean you have a high level of high-density lipoprotein, or "good" HDL cholesterol, which protects against heart disease. Or you could have other non-measured increases in LDL-like particles that can increase heart disease. Your LDL level also could be optimal if you are taking a statin medication. Please check with your doctor to get your complete lipid profile and see if you may need additional treatment. In the meantime, find more information on WebMD's Cholesterol Health Center.

Your total cholesterol level is Borderline High, but fortunately your level of "bad" LDL cholesterol is near optimal. This could mean you have a high level of high-density lipoprotein, or "good" HDL cholesterol, which protects against heart disease. Or you could have other non-measured increases in LDL-like particles that can increase heart disease. Your LDL level also could be optimal if you are taking a statin medication. Please check with your doctor to get your complete lipid profile and see if you may need additional treatment. In the meantime, find more information on WebMD's Cholesterol Health Center.

Your total cholesterol level is Borderline High. Your level of "bad" LDL cholesterol is Borderline High, too. Working to bring down your total cholesterol decreases your LDL cholesterol level. You can do this by exercising more and eating less food with saturated fats. Check food labels!

Your total cholesterol level is Borderline High. Your level of "bad" LDL cholesterol is High. Working to bring down your total cholesterol decreases your LDL cholesterol level. You can do this by exercising more and eating less food with saturated fats. Check food labels!

Your total cholesterol level is Borderline High. But your level of "bad" LDL cholesterol is Very High. Working to bring down your total cholesterol decreases your LDL cholesterol level. You can do this by exercising more and eating less food with saturated fats. Check food labels!

Your total cholesterol is High, but your level of "bad" LDL cholesterol is optimal. This could mean you have a high level of high-density lipoprotein, or "good" HDL cholesterol, which protects against heart disease. Or you could have elevated secondary lipids, such as non-HDL particles that increase the risk of heart disease. Your LDL level also could be optimal if you are taking a statin medication. Please check with your doctor to get your complete lipid profile and see if you may need additional treatment. In the meantime, find more information on WebMD's Cholesterol Health Center.

Your total cholesterol is High, but your level of "bad" LDL cholesterol is near optimal. This could mean you have a high level of high-density lipoprotein, or "good" HDL cholesterol, which protects against heart disease. Or you could have elevated secondary lipids, such as non-HDL particles that increase the risk of heart disease. Your LDL level also could be optimal if you are taking a statin medication. Please check with your doctor to get your complete lipid profile and see if you may need additional treatment. In the meantime, find more information on WebMD's Cholesterol Health Center.

Your total cholesterol level is High. Your level of "bad" LDL cholesterol is Borderline High. Working to bring down your total cholesterol decreases your LDL cholesterol level. You can do this by exercising more and eating less food with saturated fats. Check food labels!

Your total cholesterol level is High. Your level of "bad" LDL cholesterol is High, too. Working to bring down your total cholesterol decreases your LDL cholesterol level. You can do this by exercising more and eating less food with saturated fats. Check food labels! If you are struggling to bring down your total cholesterol and LDL cholesterol levels, your doctor may prescribe medication, such as statins. Following medication, dietary, and exercise instructions should result in improvements.

Your total cholesterol level is High, and your level of "bad" LDL cholesterol is Very High. Working to bring down your total cholesterol decreases your LDL cholesterol level. You can do this by exercising more and eating less food with saturated fats. Check food labels! If you are struggling to bring down your total cholesterol and LDL cholesterol levels, your doctor may prescribe statins or other cholesterol-lowering medications.

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