Approach to identifying and managing atherogenic dyslipidemia: a metabolic consequence of obesity and diabetes

Abstract

Objective: To review the evidence for recognition and management of atherogenic dyslipidemia.

Sources of information: High-quality randomized trials and meta-analyses were available to address most questions. North American and European guidelines were reviewed. Of these, the Canadian Cardiovascular Society lipid guidelines were most congruent with current literature.

Main message: Atherogenic dyslipidemia is characterized by low levels of high-density lipoprotein (HDL), high levels of triglycerides, and a high low-density lipoprotein (LDL) particle number. The condition is highly associated with cardiovascular disease (CVD) and is poorly reflected in Framingham risk score and LDL measurements. Obesity, glucose intolerance, diabetes, and metabolic syndrome are rapidly becoming more common, and are often associated with atherogenic dyslipidemia, affecting long-term CVD risk. Recognition in the office is best achieved by non-HDL or total cholesterol-HDL ratio testing. Treatment success lies in optimizing diet and exercise. Of available medications, statins produce the most benefit and can be titrated to patient tolerance rather than to LDL target levels, which have a poor evidence base. The addition of fenofibrate can be considered in patients with high triglyceride and low HDL levels who have responded poorly to or have not tolerated statins.

Conclusion: Growing obesity prevalence creates a CVD risk that might be missed by LDL cholesterol testing alone. Simple calculations from results of a non-fasting lipid panel produce non-HDL levels and total cholesterol-HDL ratio, both of which are superior for predicting risk in all patients. These metrics should be available in lipid panels.

Figure 1.

Physiology of visceral obesity and insulin resistance FFA–free fatty acids, HDL–high-density lipoprotein, LDL–low-density lipoprotein, TG–triglyceride, VLDL–very low–density lipoprotein.

Figure 2.

Risk factor characterization ApoA1–apolipoprotein A1, ApoB–apolipoprotein B, HDL–high–density lipoprotein, LDL–low–density lipoprotein. ^*Risk type: Traditional risk factors are included in the Framingham risk calculation. Novel or emerging factors are components of the metabolic syndrome and factors identified in the INTERHEART study. There is some crossover of traditional and emerging factors. ^†Risk scope: Global includes both metabolic and cardiovascular disease. Scope is otherwise primarily metabolic or cardiovascular. ^‡Risk duration: Short term is 10 years, as defined by Framingham score. Long term or lifetime indicates emerging risk factors affecting risk of events over the entire lifespan. ^§Risk relevance: Absolute is defined as a primary source of risk as defined in current guidelines. Relative adds or subtracts an increment to primary risk. ^||Risk identification: Usefulness of laboratory tests in the detection of lipid abnormalities resulting from contributing risk factors. Data from Genest et al, Alberti et al, and Yusuf et al.