Atherosclerotic cardiovascular disease remains the leading cause of mortality in the United States with elevated low-density lipoprotein cholesterol (LDL-c) as one of the major underlying risk factors. Emerging data suggests that cumulative exposure to total LDL cholesterol over time is a strong determinant for the development of cardiovascular disease. Therefore, it becomes critical that we need to educate patients and providers about early identification of high-risk cholesterol profiles and recommend early treatment through dietary and therapeutic modification.
To increase system wide identification and awareness of high cholesterol, we propose updating our current lipid panel with more robust interpretive lab commenting to reflect update guidelines since many patients now have access to their own lab data online as part of the 21St Century CURES Act which includes a provision requiring that patients can now electronically access all their electronic health information at no cost. The major goal of interpretive lab commenting is to provide a framework for patients and providers to understand lab values of the following elements: 1) the presence or absence of an abnormality and its degree of severity 2) possible clinical implications of abnormality and/or diagnosis and 3) suggested follow up further testing and potential specialist referral. Several studies from Australia and Europe suggest that more informative interpretive commenting on our current lipid profile can improve detection of patients with high-risk lipid profiles and lead to earlier treatment.
Specifically, we think it is important to highlight three particular subpopulations within the comment section. First, adults with LDL-c > 190mg/dL should be flagged to alert the clinician and patient that this is a high risk finding that could be suggestive of familial hypercholesterolemia (FH). FH is predominantly driven by genetics and has a prevalence of 1 in 200 with 20-fold increase in premature heart disease. Studies have demonstrated that early initiation of lipid lowering agent can significantly blunt the risk of atherosclerotic disease. Second, for those with established atherosclerotic disease (coronary disease, peripheral arterial disease, stroke), we need to highlight that patients who achieve a lower LDL-c cholesterol (< 70mg/dL US guidelines, < 55 mg/dL European guidelines) have improved short and long term cardiovascular outcomes. Third, for the general population for primary prevention, we need to emphasize that patients with mild or moderately elevated LDL-c levels are at risk for future cardiovascular disease if they have additional risk enhancers such as family history, diabetes, hypertension, autoimmune/inflammatory disease, or chronic kidney disease.
To our knowledge, there is limited literature on the use of lipid panel interpretive commenting to change patient and provider behavior in the United States, so this also presents an opportunity for quality improvement studies. Additionally, we want to learn and share best practice examples of interpretive commenting for lipid panel across various hospital and laboratory systems in a continued effort to improve patient and provider education.
- Bender R, Edwards G, MacMahon J et al. Interpretive comments specifically suggesting specialist referral increases detection of familial hypercholesterolaemia. Pathology 2016; 48: 463-466.
- Grundy SM, Stone NJ, Bailey AL, et al. AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2019; 73:e285-e350.
- Wilson PWF, Jacobson TA, Martin SS, Jackson EJ, Le NA, Davidson MH, Vesper HW, Frikke Schmidt R, Ballantyne CM, Remaley AT. Lipid measurements in the management of cardiovascular diseases: Practical recommendations a scientific statement from the national lipid association writing group. J Clin Lipidol. 2021 15(5):629-648. Bender R, Edwards G, MacMahon J et al. Interpretive comments specifically suggesting specialist referral increases detection of familial hypercholesterolaemia. Pathology 2016; 48: 463-466.