Déjà Vu All Over Again

Current guidelines recommend the use of standard lipid measures, including the total to high-density lipoprotein cholesterol ratio, inexpensive and readily available, for routine cardiovascular disease risk assessment.1 Other studies and consensus panels, however, have suggested that the number of circulating atherogenic particles (and apoB as a surrogate) provide better risk prediction than standard lipid measures.2 Tests such as the Vertical Auto Profile (Atherotech, Birmingham, AL), which determines the cholesterol content of very low density lipoprotein, low-density lipoprotein (LDL), and high-density lipoprotein (HDL) subclasses, and patterns of LDL size; and nuclear magnetic resonance (NMR) spectroscopy, which determines the sizes and concentrations of lipoprotein particles, have been described as improving the predictive power of lipid measurements.3,4 At times, there has been intense debate in the literature over the relative merits of these tests versus the standard lipid profile.5 The clinical popularity of lipid subfractionation and particle number and size measurements varies widely, but it is not uncommon to have patients specifically ask for these tests, and multiple web sites suggest that, if your physician is not knowledgeable about such studies, he or she is simply not to be thought of as keeping up with the times.Article see p 2469The data, however, do not consistently support the additional value of these studies when added to standard lipid profile measurement. Ingelsson and colleagues6 used data from the Framingham Heart Study to assess the incremental utility of apolipoproteins over traditional lipids for coronary heart disease prediction. They followed 3322 middle-aged participants (53% women) for a median of 15 years. The primary outcome measure was incidence of first …