While mainstream medicine is stuck in the dark ages, obsessing over the standard lipid panel and particularly obsessing over the wrong things in the lipid panel, you should be looking to other ways to assess cardiovascular risk that are more meaningful.
Lipoprotein Sub-particle Testing
If you want to obsess over lipids, request a NMR LipoProfile or VAP – these tests measure the both the particle number of lipoproteins directly and the particle sizes. These tests are performed using Nuclear Magnetic Resonance (NMR) imaging, the technology behind MRI scans.
The lipoprotein particle number is more predictive of cardiovascular risk than the cholesterol concentration, which can be skewed by large cholesterol particles, or apolipoprotein B (ref). Thus, even if the LDL-C (calculated LDL concentration) is low, there may be a high number of small, dense LDL’s that are considered high-risk.
It’s also important to assess the presence of small, dense LDL cholesterol particles, which are considered more atherogenic (likely to cause vascular disease) than large, fluffy LDL particles.
Small, dense LDL particles are associated with Metabolic Syndrome, i.e. Insulin Resistance. The number of small, dense LDL particles correlates most prominently with triglycerides and HDL-C (ref).
While it is more expensive and often considered by insurance companies to be an experimental test only, it is much more valuable data than you can get from a standard lipid panel.
Here is a sample report from the NMR LipoProfile on one of my patients.
Oxidized LDL
Oxidative stress is inflammation that results in LDL particles becoming atherogenic. Oxidation is the same process by which metal rusts and causes inflammation. The level of oxidation among the LDL particles associates with cardiovascular disease risk (ref, ref).
High-sensitivity C-Reactive Protein (hsCRP)
C-reactive protein is a nonspecific marker of inflammation. In the absence of acute inflammatory conditions, it serves as an independent risk factor for cardiovascular disease (ref, ref). Elevation of the CRP correlates with insulin resistance, excess body fat, and other metabolic derangements.
Lipoprotein(a)
It’s argued that Lp(a) is an important metric that should be measured at least once in someone’s life. Theoretically, it is determined quite a bit by genetics. I have a different slant. We have evidence that Lp(a) is increased by the use of statins. Furthermore, if it is determined mostly by our genetics, I’m not terribly interested in checking it. If it’s high, you get to live with the stress of worrying about it, since you’re not going to do much in the way of changing your genetics. I prefer instead to focus on improving my overall health regardless of any lab test. Having a normal level of Lp(a) doesn’t give you license to abuse your body.
Apolipoprotein B
ApoB is considered to be more important than LDL as a marker of cardiovascular disease risk, but it’s really one and the same. Every LDL particle contains an ApoB, as does every VLDL, IDL, Lp(a), and chylomicron, and thus the ApoB level correlates with the LDL particle level. Another test not worth the stress for me.
Homocysteine
While homocysteine has been identified as a possible risk factor, lowering homocysteine in individuals with cardiovascular disease has not shown any benefit (ref).
Remnant cholesterol
Remnant cholesterol refers to the triglyceride-rich lipoproteins and can be calculated as Triglycerides divided by 5 (TG/5). (ref) The importance of triglycerides in cardiovascular is increasingly being recognized (ref), as remnant cholesterol is considered a meaningful risk factor (ref, ref).
In fact, the most meaningful data from the standard lipid panel is the Triglyceride/HDL ratio. A ratio greater than 2:1 is suggestive of insulin resistance. Thus, a low ratio (ideally close to 1:1) is preferred.
Summary
A standard lipid panel provides little insight into one’s risk for cardiovascular disease, and most doctors interpret lipid panel results in a binary fashion: normal or abnormal. There are more meaningful ways to interpret the lipid panel, as well as other tests that are more useful indicators of cardiovascular risk.
