Experts highlight important literature in lipidology

PHILADELPHIA — Nutrition, gene variants and familial hypercholesterolemia were the topics of three important journal articles discussed at the National Lipid Association Scientific Sessions.

The literature was highlighted in a joint presentation from Jessica Durham, MA, RN, ARNP‐BC, ANP, GNP, CLS, clinical lipid specialist at the Lipid Clinic in Seattle, Carol Kirkpatrick, PhD, MPH, RDN, CLS, FNLA, clinical associate professor and director of the Wellness Center at Idaho State University, and James A. Underberg, MD, MS, FACPM, FACP, FASH, FNLA, FASPC, clinical assistant professor of medicine at NYU School of Medicine and the NYU Langone Center for Cardiovascular Disease Prevention, director of Bellevue Hospital Lipid Clinic, and new president of the NLA.

Using study results and case studies for which they apply, the three presenters set out to educate professionals from different backgrounds on important cases that they may otherwise know little about.

"We need to put together an interesting and a different type of program, so I'm going to find some really smart people to teach me something," Underberg said. "There's stuff going on in all of our different areas that we don't know about."

Nutrition controversies

Kirkpatrick discussed a study evaluating concurrent trends in nutrients, foods and dietary patterns. The study, which was published in the Journal of the American College of Cardiology and written by Andrew M. Freeman, MD, and colleagues, reviewed observational studies randomized controlled trials and meta-analyses looking at evidence available on current controversial dietary patterns, foods and nutrients.

The study found that the Southern diet pattern consisting of a high intake of fried foods, added salt and fats, organ meats, processed meats, eggs and sugar-sweetened beverages increased CVD risk or risk factors; the authors recommended that patients avoid this dietary pattern.

Researchers also found that dietary cholesterol increases serum levels of cholesterol and recommended continuing to encourage patients to limit dietary cholesterol.

Kirkpatrick presented a related case study, citing a woman aged 52 years who was postmenopausal and was referred to a lipid clinic for acute rise in serum lipids.

The subject adhered to a pescatarian diet and consumed a large amount of coconut cream and oil per week, which caused an increase across the lipid panel.

Post-consultation, the patient discontinued the coconut cream/oil consumption and experienced a drop in LDL and non-HDL six weeks later, Kirkpatrick said.

"Coconut oil and palm oil are very rich in saturated fatty acids,” she said. “The case study illustrates nicely that they can increase the atherogenic lipids and we want to encourage them to avoid that."

SCARB1 variants

Underberg highlighted an article published in Circulation: Cardiovascular Genetics on the SCARB1 gene, which showed that there were variants associated with the phenotype of combined high HDL and elevated lipoprotein(a).

The researchers performed sequencing of SCARB1 exons in 18 patients from the GeneSTAR and Copenhagen City Heart Study cohorts with HDL > 80 mg/dL and Lp(a) > 100 nmol/L. Of those, 15 demonstrated genetic variants, and functional studies with four of the SCARB1 variants showed decreased receptor function in vitro.

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For his case study, Underberg discussed a woman aged 56 years with high HDL and subclinical atherosclerosis confirmed by coronary artery calcium testing. The patient had a total Agaston Score of 183, total cholesterol 247 mg/dL, HDL 114 mg/dL, triglycerides 84 mg/dL, LDL 116 mg/dL and Lp(a) 299 nmol/L.

According to Underberg, the case study offers up the following take home messages;

Patients with significantly increased levels of HDL may be at increased risk for atherosclerotic CVD;
Mutations of the SRB‐1 receptor can cause elevated HDL levels and is linked to increased risk for atherosclerotic CVD;
The SRB‐1 receptor may play a role in clearing Lp(a);
High HDL due to SRB‐1 mutations can be associated with Lp(a) elevations;
Patients with increased HDL and premature or unexplained atherosclerotic CVD should have Lp(a) testing.

“This may lead to appropriate family screening and identify patients who will benefit from more aggressive LDL lowering or for novel Lp(a)-lowering agents in development,” Underberg said

Predicting risk in FH

Durham discussed the results of the cross-sectional retrospective cohort study of 20,434 patients at the Nutrition, Metabolism and Atherosclerosis Clinic in Montreal. The results were presented at NLA.

According to Durham, the Montreal-FH-Score was shown to be a risk stratification tool that can assist providers in predicting CVD risk in patients with familial hypercholesterolemia (FH). While validation is still required in other populations, the results of the study are promising, she said.

For the case study, Durham discussed a man aged 49 years with baseline LDL > 220 mg/dL, a family history of CABG and FH.

The patient started bile acid therapy at age 12 years and has a Lp(a) of 28 mg/dL.

The Montreal-FH-Score for the patient was 23 and included factors such as age, sex, HDL, hypertension, smoking and CHD prevalence.

According to Durham, physicians should look for FH, talk with patients about it by name, educate patients on the associated CVD risk, refer them to the FH foundation website, use the e78.01 ICD-10 code and screen family members.

"The Montreal-FH-Score provides a rich stratification tool that can assist providers in predicting CV risk in FH patients," she said. "I'd like to see how the model applies to other populations."– by Dave Quaile

Reference:

Durham J.
Kirkpatrick C.

Underberg JA. Important Journal Articles from the Past Year: A Multidisciplinary Overview with Clinical Case-Based Applicability. All presented at: National Lipid Association Scientific Sessions; May 18-21, 2017; Philadelphia.

Disclosure: Durham and Kirkpatrick report no relevant financial disclosures. Underberg reports financial ties with Aegerion, Alexion, Akcea, Amarin, Amgen, Ivitae, Kastle, Pfizer, Regeneron, Sanofi and True Health Diagnostics.