1

Laboratory aspect of Dyslipidemia

Banundari Rachmawati
Bag Patologi Klinik FK UNDIP
 2

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 Dyslipidemia
• is elevation of plasma cholesterol,
triglycerides (TGs), or both, or a low high-
density lipoprotein level that contributes to the
development of atherosclerosis.
• Causes may be primary (genetic) or
secondary.
• Diagnosis is by measuring plasma levels of
total cholesterol, TGs, and individual
lipoproteins.
.
 Lipid Metabolism
• Cholesterol
synthesis
• Lipoproteins:
VLDL

LDL

HDL

• Chylomicrons
 5

Today’s Safer Values

 Total Cholesterol < 200
 Triglycerides < 150
 LDL Cholesterol < 100 preferably <
70
 HDL Cholesterol > 50 (for women
55)
 Bad Cholesterols the lower the
better
 Good Cholesterols the higher the
better
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 6

Dyslipidemia based on TG and LDL

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 Dyslipidemia based on TG and Apo 7

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Normal Arterial Wall

Tunica adventitia

Tunica media

Tunica intima
Endothelium

Subendothelial connective
tissue

Internal elastic membrane

Smooth muscle cells

Elastic/collagen fibers

External elastic membrane

Development of Atherosclerotic Plaques

Fatty streak
Normal

Lipid-rich plaque

Foam cells

Fibrous cap

Lipid core
Thrombus
 Vulnerable vs Stable Atherosclerotic
Plaques
Vulnerable Plaque
Lumen Lipid • Thin fibrous cap
Fibrous Cap
Core • Inflammatory cell infiltrates:
proteolytic activity
• Lipid-rich plaque

Stable Plaque
Lumen • Thick fibrous cap
Lipid
Core
• Smooth muscle cells:
Fibrous Cap more extracellular matrix
• Lipid-poor plaque

Libby P. Circulation. 1995;91:2844-2850.

 Thrombosis Influences the Severity of a
Cardiovascular Event

Nonocclusive thrombus Occlusive thrombus

• Unstable angina • Q-wave MI

• Non—Q-wave MI • Sudden death

Factors limiting thrombosis: Factors favoring thrombosis:

• Minor plaque • Major plaque disruption
disruption
• Low flow or vasospasm
• High flow
• Thrombotic tendency
• Low thrombotic
tendency
Kullo IJ, et al. Ann Intern Med. 1998;129:1050-1060.
 Global cardiometabolic risk*

Gelfand EV et al, 2006; Vasudevan AR et al, 2005

* working definition
Interrelation Between Atherosclerosis and Insulin
Resistance

Hypertension
Obesity
Hyperinsulinemia

Insulin Diabetes
Resistance Atherosclerosis
Hypertriglyceridemi
a
Small, dense LDL
Low HDL
Hypercoagulability
 Mechanisms Relating Insulin Resistance and
Dyslipidemia
Fat Cells Live
r
FFA

X
IR

Insulin
 Mechanisms Relating Insulin Resistance and
Dyslipidemia
Fat Cells Live
r
FFA

 TG VLDL
 Apo
IR X B
 VLDL

Insulin
 Mechanisms Relating Insulin Resistance and
Dyslipidemia
Fat Cells Live
r
FFA CE

 TG VLD (CETP) HD
(hepati
 Apo L c
L
X B lipase)
IR TG
 VLDL Apo A-
1
Kidne
Insulin y
 Mechanisms Relating Insulin Resistance and
Dyslipidemia
Fat Cells Live
r
FFA CE

 TG VLD (CETP) HD
(hepati
 Apo L c
L
X B lipase)
IR TG
 VLDL Apo A-
CE (CETP) TG 1
Kidne
Insulin y
SD
LD
LDL
L
(lipoprotein or hepatic
lipase)
Classification of Dyslipidemia
 Fredrickson Classification
Type Elevated Associated clinical Serum Serum
particles disorders TC TG

I Chylomicrons Lipoprotein lipase ↔ ↑↑

deficiency, apolipoprotein
C-II deficiency
IIa LDL Familial ↑↑ ↔
hypercholesterolemia,
polygenic
hypercholeterolemia,
nephrosis, hypothyroidism,
familial combined
hyperlipidemia
IIb LDL, VLDL Familial combined ↑↑ ↑
hyperlipidemia
 Fredrickson Classification
Type Elevated Associated clinical Serum Serum
particles disorders TC TG

III IDL Dysbetalipoproteinemia ↑ ↑

IV VLDL Familial ↔↑ ↑↑
hypertriglyceridemia,
familial combined
hyperlipidemia, sporadic
hypertriglyceridemia,
diabetes

V Chylomicrons, Diabetes ↑ ↑↑
VLDL
 Secondary Causes of Lipoprotein
Abnormalities

• Hypothyroidism; Obstructive liver

Hypercholesterolemia disease; Nephrotic syndrome; Drugs:
progestogens, cyclosporine, thiazides

• Obesity, DM, Pregnancy, CRF, Alcohol,

Stress, Sepsis, Acute hepatitis, SLE,
Hypertriglyceridemia Drugs: estrogen, β-blockers, steroids,
acid resins, thiazides

• Type-2 DM, Rheumatoid arthritis, Malnutrition,

Low HDL
Obesity, Cigarette smoking, Beta blockers
 22

Two Types of Lipids

LIPIDS IN BLOOD

TOTAL
TRIGLYCERIDES (TG)
CHOLESTEROL

GOOD
CHOLESTEROL
HDL 1 and HDL 2

BAD CHOLESTEROL
LDL, VLDL (TG), Lp(a)
 23

Composition
of
Lipoprotein
 classification based
Lipoproteins on the relative
densities of the
aggregates on
ultracentrifugation

TG EC

Apoprotein boat

Apo A I and A II for HDL Apo B100 for LDL

Apo B100+C+E for VLDL, IDL Apo B100+Apo(a) for Lp(a)

24
 Good, Bad, Ugly & Deadly

HDL GOOD LDL BAD

C C
T TG
G
A I, A II B 100

VLDL UGLY Lp(a) DEADLY

TG
TG C TG C
B 100 + E +C B 100+ (a)

25
 All are the terrorists !!
Apolipoprotein B
Measurements Non-HDL-C

VLDL VLDLR IDL LDL SDL

TG-rich lipoproteins Highly atherogenic

26
 27

Lipid Profile Report

LIPIDS
ESTIMATED

TOTAL
TRIGLYCERIDES
CHOLESTEROL
HDLc LDLc VLDLc (TG) VLDL
Chylomicrons
(TC)

PP Fasting
 28

Normal Lipid Profile

• Total Cholesterol < 200
• TG ‘Ugly’ Lipid < 150
• ‘Bad’ Cholesterols LDL < 100
• HDL ‘Good’ cholesterol > 50
• VLDL is Ugly TG ÷ 5 < 30
• Lp(a) ‘Deadly’ cholesterol < 20
 Normal range

Element Optimal Borderline High risk

LDL C <100 130–159 160+

HDL C >60 35–45 <35
Triglycerides <150 150–199 >200
Total Choles. <200 200–239 >240
Cholesterol
 Specimen
• Serum, Plasma (EDTA, Heparin)
• Certain anticoagulants, such as fluoride, citrate, and
oxalate, cause large shifts of water from the red blood
cells to the plasma, which result in the dilution of
plasma components.

• Storage and Stability

 7 days at 20 – 25 °C
7 days at 4 – 8 °C
3 months at -20 °C
Triglycerides
 Specimen
• Serum
• Plasma (EDTA) or heparin
• Certain anticoagulants, such as fluoride, citrate,
and oxalate, cause large shifts of water from the
red blood cells to the plasma, which result in the
dilution of plasma components.
• Fasting sample (from 12 to 16 h) is essential for
triglyceride analysis
• Storage and stability
 Triglycerides

TG Level Classification Treatment

< 150 mg% Normal TG No Rx.

150 to 200 mg% Borderline high Diet alone

201 to 500 mg% High Diet + drugs

> 500 mg% Very high Diet + Intensive Rx

NCEP 2004 Guidelines by expert panel on TG

 HDL
• HDL is a fraction of plasma lipoproteins

• It is composed of 50% protein, 25% phospholipid,

20% cholesterol, and 5% triglycerides

• Evidence suggests that high-density lipoprotein

(HDL) cholesterol is cardioprotective.
Diagnosis

How to Calculate LDL

Cholesterol?
• HDL & TGs are measured directly in the
lab
• LDL can be calculated using a specific
equation

LDL-C = Total Cholesterol – (HDL-C + TG/5)

 Limitations of the Friedewald equation
• The Friedewald equation should not be used
under the following circumstances:
when chylomicrons are present.
when plasma triglyceride concentration exceeds 400
mg/dL (4.52 mmol/L).
in patients with type III hyperlipoproteinemia.
• LDL can also be measured directly using
plasma ultracentrifugation and by an
immunoassay method.

• Direct measurement may be useful in some

patients with elevated TGs, but these direct
measurements are not routinely necessary.
• TC, TGs, and HDL cholesterol are measured directly

• TC and TG values reflect cholesterol and TGs in all

circulating lipoproteins, including chylomicrons,
VLDL, IDL, LDL, and HDL.

• TC values vary by 10% and TGs by up to 25% day-

to-day
 40

• TC and HDL cholesterol can be measured

in the nonfasting state, but most patients
should have all lipids measured while
fasting for maximum accuracy and
consistency.
• Patients with an extensive family history of
heart disease should also be screened by
measuring Lp(a) levels.

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 Discussion
Interpretation of Results
Diagnosis

Classification of Lipid Levels

Total cholesterol
LDL cholesterol mg/dl
mg/dl
< 200 Desirable < 100 Optimal

Near
Border line
200-239 100-129 optima/Above
high
optimal

Borderline
130-159
high
≥ 240 High 160-189 High

≥ 190 Very high

CEP ATP III Classification of Blood Lipids

Diagnosis

Classification of Lipid Levels

Triglycerides mg/dl HDL cholesterol mg/dl

< 150 Normal

< 40 Low
Border line
150-199
high

200-400 High
≥ 60 High
≥ 500 Very high

CEP ATP III Classification of Blood Lipids

Risk Assessment

Non Lipid Risk Factors for CHD

Modifiable Risk Non Modifiable Risk
Factors Factors
Hypertension Age
Cigarette smoking Male
Thrombogenic/ Family history of
hemostatic state premature CHD
Diabetes
Obesity
Physical inactivity
Atherogenic Diet
How to interpret Lipid Profile Report?

A. Total Cholesterol 200

HDL Cholesterol (Soldiers) - Good 50
Non HDL Cholesterol (Culprits) 150
LDL Cholesterol – Bad fellows 100
Lipoprotein(a) – Deadly fellows 20
VLDL Cholesterol (1/5 of TG)- Ugly 30
B. Triglycerides 150
Normal Lipid Profile
Interpret this Lipid Profile Report
A. Total Cholesterol 240
HDL Cholesterol (Soldiers) - Good 50
Non HDL Cholesterol (Culprits) 190
LDL Cholesterol – Bad fellows 140
Lipoprotein(a) – Deadly fellows 20
VLDL Cholesterol (1/5 of TG)- Ugly 30
B. Triglycerides 150
Hyper cholesterolimia ↑LDL, HDL, TG, Lp(a) - N
 Interpret this Lipid Profile Report

A. Total Cholesterol 200

HDL Cholesterol (Soldiers) - Good 50
Non HDL Cholesterol (Culprits) 150
LDL Cholesterol – Bad fellows 70
Lipoprotein(a) – Deadly fellows 20
VLDL Cholesterol (1/5 of TG)- Ugly 60
B. Triglycerides 300
Hyper triglyceridemia ↑TG, HDL, LDL, Lp(a) - N
 Interpret this Lipid Profile Report

A. Total Cholesterol 160

HDL Cholesterol (Soldiers) - Good 25
Non HDL Cholesterol (Culprits) 135
LDL Cholesterol – Bad fellows 85
Lipoprotein(a) – Deadly fellows 20
VLDL Cholesterol (1/5 of TG)- Ugly 30
B. Triglycerides 150
Low HDL : ↓HDL, LDL, TG, Lp(a) - N
 Interpret this Lipid Profile Report

A. Total Cholesterol 200

HDL Cholesterol (Soldiers) - Good 45
Non HDL Cholesterol (Culprits) 155
LDL Cholesterol – Bad fellows 75
Lipoprotein(a) – Deadly fellows 50
VLDL Cholesterol (1/5 of TG)- Ugly 30
B. Triglycerides 150
High Lipoprotein(a) : ↑Lp(a) , HDL, LDL, TG - N
 Interpret this Lipid Profile Report

A. Total Cholesterol 200

HDL Cholesterol (Soldiers) - Good 25
Non HDL Cholesterol (Culprits) 175
LDL Cholesterol – Bad fellows 95
Lipoprotein(a) – Deadly fellows 20
VLDL Cholesterol (1/5 of TG)- Ugly 60
B. Triglycerides 300
High Lipoprotein(a) : ↓HDL, ↑TG, LDL, Lp(a) - N
 Interpret this Lipid Profile Report
A. Total Cholesterol 260
HDL Cholesterol (Soldiers) - Good 50
Non HDL Cholesterol (Culprits) 210
LDL Cholesterol – Bad fellows 120
Lipoprotein(a) – Deadly fellows 40
VLDL Cholesterol (1/5 of TG)- Ugly 50
B. Triglycerides 250
Combined Dyslipidemia : ↑ TC↑LDL↑TG ↑Lp(a)
 Look at the risks
• Low HDL + High LDL +
• LP(a) excess > 30 mg% +
• LP(a) excess > 30 mg% + LDL high ++
• LP(a) excess > 30 mg% + low HDL +++
• LP(a) excess > 30 mg% + Incr. tHCy ++++
• LP(a) excess + Incr. tHCy + low HDL +++++
• Circulating lipids are one aspects
• Tissue lipid content is more important

J. Atherosclerosis : Hopkins PN, 1997 – 17, 2792

 Clinical Action
• For all above 20 years once in every 5 years
• For those above 45 yrs – once in 2 years
• For those with already known lipid
abnormality follow-up every 3-6 months
• Extended Lipid profile includes
Homocysteine, LP(a), SD-LDL, ALP, Apo A
and Apo B, hS-CRP
• There is no natural cutoff between normal and
abnormal lipid levels because lipid measurements
are continuous
• A linear relation probably exists between lipid levels
and cardiovascular risk
 55

• elevated TG and low HDL levels are more

predictive of cardiovascular risk in women than in
men
• HDL levels do not always predict cardiovascular
risk. High HDL levels caused by some genetic
disorders may not protect against cardiovascular
disorders, and low HDL levels caused by some
genetic disorders may not increase the risk of
cardiovascular disorders.
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• Proof of treatment benefit is strongest for lowering
elevated low-density lipoprotein (LDL) levels.
• In the overall population, evidence is less strong for
a benefit from lowering elevated TG and increasing
low high-density lipoprotein (HDL) levels, in part
because elevated TG and low HDL levels are more
predictive of cardiovascular risk in women than in
men
 LDL Goals
Risk Category LDL-C Goal Initiate Lifestyle Consider Drug
Change Treatment
High Risk (20%) < 100mg/dl  100mg/dl  100mg/dl
CHD or CHD
equiv
Moderately High < 130mg/dl  130mg/dl  130mg/dl
Risk  2 risk
factors (10-20%)
Moderate Risk < 130mg/dl  130mg/dl  160mg/dl
 2 risk factors
(10%)
Low Risk < 160mg/dl  160mg/dl  190mg/dl
0-1 risk factors