Reducing CVD risk - integration of clinical and laboratory criteria.

BACKGROUND: Recent updates to National Heart Foundation of Australia (NHFA) Lipid management guidelines and Pharmaceutical Benefits Scheme (PBS) criteria for subsidised lipid lowering therapy have resulted in greater alignment between the two documents. However, several recommendations, such as the need to focus on low density lipoprotein cholesterol level rather than total cholesterol, while well supported in the literature, may initially create confusion for both patients and clinicians. OBJECTIVE: This article summarises the likely pathology reporting changes that will occur as a result of a recent review of NHFA guidelines by the Australian Pathology Lipid Interest Group; compares current PBS criteria for subsidised lipid lowering therapy to the NHFA high risk categories and treatment targets; and provides an algorithm for treatment based on the PBS criteria integrating risk factors and lipid levels. DISCUSSION: Although pathology testing plays an important role in the assessment of risk in patients, it is ultimately the clinician who must determine the patient's absolute risk based on all relevant previous and current clinical information before the initiation or review of appropriate treatment.

Recommendations for lipid testing and reporting by Australian pathology laboratories.

The importance of measuring blood lipids in determining the absolute risk of a cardiovascular event is now well established. In Australia, the National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand (NHFA/CSANZ) have done much to educate doctors. In recent years the recommendations of the NHFA/CSANZ have been based on values for Low-density lipoprotein (LDL-C) as well as High-density lipoprotein cholesterol (HDL-C) and Triglyceride (TG). This change has been reflected in requests to pathology laboratories. However the interpretation of these results may be difficult and the NHFA guidelines outline desirable values for patients at high risk only. There are no formal recommendations for reference intervals or interpretive comments. With the availability of expert systems, some pathology laboratories are now in a better position to provide specific comments to assist with the interpretation of test results. An ad hoc committee of private and public chemical pathologists met to draft recommendations for lipid testing and reporting by Australian pathology providers, on the basis of current guidelines and their own expertise. Provisions in the current Medicare Benefits Schedule (MBS) for lipid testing were reviewed, and the indications for lipid testing, recommended tests, the logistics of managing specimens, methods of analysis and availability of specialised tests have been documented. Recommendations are made on the provision of desirable values for lipid tests. Suggestions are provided on interpretive comments which could accompany reports of lipid test results, including categorisation of the likely associated lipoprotein abnormalities, their causes, contribution to risk for cardiovascular disease (CVD) and targets for treatment. Current and future approaches to the assessment of risk for CVD are discussed.