Clinical Lipidology and the Prevention of Vascular Disease: Time for Personalized Therapy.

Genetic, metabolic, and lifestyle modifications can cause elevations of lipoproteins that contribute to atherosclerotic lesions over time. In the modern world with life extension from many improvements in medicine and public health, most humans live long enough to develop atherosclerosis with concentrations of blood plasma lipoproteins that are very common. Familial abnormalities are prevalent and provide additional challenges in identifying unhealthy but treatable values of low-density (LDL) and very low-density lipoproteins (VLDL). Multiple community studies and clinical trials have provided guidance on selecting targets and new tools that make possible effective goals of treatment. Lipid-lowering drugs are making it possible to achieve those goals and place responsibility on physicians to master the art of preventing atherosclerotic events. Lipoprotein management remains a very focused effort and requires an artful individualized approach for each patient. Few skills are more important for healthcare providers in primary care and cardiovascular medicine.

Roundtable discussion: Familial chylomicronemia syndrome: Diagnosis and management.

Plasma triglyceride concentrations are normally below 150 mg/dL in the fasting state. However, these lipids can reach values of several thousand mg/dL. Elevations in this range are due to a massive retention of chylomicrons and usually result from multiple genetic variants with superimposed influences such as diabetes and immune disorders. Less commonly, major gene defects in lipoprotein metabolism can be the cause. These may present soon after birth with strong evidence of familial penetrance. The causes of this syndrome have been discussed in a Roundtable published in the most recent issue of this Journal. The polygenic etiology may also have a familial presentation with similar clinical import. The diagnosis and management of these disorders is of importance since they can lead to critical clinical syndromes including death from acute hemorrhagic pancreatitis. The chronic management requires a dedicated medical team and a patient committed to an effective regimen. We are joined in this discussion by Dr P. Barton Duell, University of Oregon Health Sciences Center, and Dr Daniel Gaudet of the Université de Montreal, Montreal, Quebec. All have had extensive personal experience in the diagnosis and management of patients with familial chylomicronemia. This Roundtable was recorded on November 11, 2017, during a meeting of the National Lipid Association in New Orleans, Louisiana.

JCL roundtable: Future of the lipid laboratory: Using the laboratory to manage the patient (part 2).

The measurement of cholesterol and triglycerides as indicators of metabolic disorders and most particularly of vascular disease risk has been of growing importance to physicians and epidemiologists over the past century. This was refocused on the lipoproteins, the specific packages in blood that carry these lipids, by John Gofman, MD, PhD, and Don Fredrickson, MD, more than 50 years ago. We continue to learn about the metabolism of these large molecular structures and their relationship to arteriosclerosis as new genetic and interventional studies are published. The clinical laboratory has evolved to provide more focused information with measures that can help us assess risk and target our therapy more effectively. In this roundtable discussion, I had the opportunity to talk with physicians who consider lipoprotein management to be central features of their practice every day. They personally care for patients with metabolic disorders in which the lipoproteins have caused disease or are predicted to do so. They are well-versed on the way that science is leading us in our field. I believe that you will learn from their view of current needs regarding lipoprotein measures and the changes that may derive from ongoing scientific studies in our field.

JCL roundtable: Future of the lipid laboratory: Choosing valuable measures among the lipoproteins (part 1).

The measurement of cholesterol and triglycerides as indicators of metabolic disorders and most particularly of vascular disease risk has been of growing importance to physicians and epidemiologists over the past century. This was refocused on the lipoproteins, the specific packages in blood that carry these lipids, by John Gofman, MD, PhD, and Don Fredrickson, MD, more than 50 years ago. We continue to learn about the metabolism of these large molecular structures and their relationship to arteriosclerosis as new genetic and interventional studies are published. The clinical laboratory has evolved to provide more focused information with measures that can help us assess risk and target our therapy more effectively. In this roundtable discussion, I had the opportunity to talk with physicians who consider lipoprotein management to be central features of their practice every day. They personally care for patients with metabolic disorders in which the lipoproteins have caused disease or are predicted to do so. They are well-versed on the way that science is leading us in our field. I believe that you will learn from their view of current needs regarding lipoprotein measures and the changes that may derive from ongoing scientific studies in our field.

JCL roundtable: Cardiovascular disease risk reduction in menopausal women.

Ovarian failure occurs in most women during the late fifth decade or early sixth decade of life. This causes a number of changes in physiology as estrogen and progestin concentrations decline. These involve lipoprotein metabolism and the vasculature. The risk factors for large vessel disease increase, and dysfunction of the small resistance vessels responds with changes in blood flow to the skin causing unpleasant symptoms. These and other changes result in visits to the physician. A reassessment of risk factors and symptoms is needed to develop a new plan for effective management, both short term and long term.

JCL roundtable: Managing lipid disorders in young women.

The roundtable discussion in this issue will focus on the problems faced by young women with lipid disorders. This is often the source of confusion for the patient and physician because the myth continues that young women do not have complications of atherosclerosis as a result of elevated blood cholesterol. The essential role of women in bearing children during the early years of adulthood also produces difficult decisions because the mother and fetus are usually experiencing similar exposure to therapeutic regimens. We are joined in this discussion by Drs. Pamela Morris of the Medical University of South Carolina and Robert Wild of the University of Oklahoma Health Sciences Center. Dr Morris is an Internist, and Dr Wild is an Obstetrician and Gynecologist. Both are board certified in clinical lipidology and are actively publishing in this field. We have recorded this roundtable discussion during the National Lipid Association Scientific Sessions held in New Orleans during May 2016.

JCL roundtable: Diagnosis and clinical management of lipodystrophy.

Lipodystrophy comes in several forms, some involving the complete failure to develop adipose tissue and others with a partial absence in various bodily distributions. All appear to have a major genetic basis, and all involve a high frequency of lipoprotein disorders. High triglycerides and low high-density lipoprotein cholesterol are the usual findings that raise interesting questions as to how such abnormalities characteristic of obesity can be caused by genetic variants that produce a paucity of adiposity. We are learning to link some specific genetic variants that seem causal and to manage these disorders in more effective ways. We are joined by 3 experts who have been leaders in the study of the clinical presentation, genetics, abnormal physiology, and the management of lipodystrophy in recent years. They are Drs Abhimanyu Garg from the University of Texas Southwestern, Phillip Gorden of the National Institute of Diabetes, Digestive and Kidney Diseases, and Robert Shamburek of the National Heart, Lung and Blood Institute.