Consensus Panel Recommendation for Incorporating Lipoprotein-Associated Phospholipase A₂ Testing into Cardiovascular Disease Risk Assessment Guidelines

Inflammatory markers incorporated into the National Cholesterol Education Project Adult Treatment Panel III (ATP III) guidelines as adjunctive to risk assessment. The ATP III guidelines incorporated the optional use of inflammatory markers in moderate-risk persons to intensify lowering of the LDL cholesterol (LDL-C) target from <130 mg/dL to <100 mg/dL (1 mg/dL = 0.02586 mmol/L). CAD = coronary artery disease; CV = cardiovascular; FRS = Framingham risk score; HDL = high-density lipoprotein; TIA = transient ischemic attack. (Adapted from Circulation.)

Recommendation for use of lipoprotein-associated phospholipase A₂ (Lp-PLA₂) testing. The consensus panel endorses Lp-PLA₂ testing in moderate-risk persons determined as having simply 2 risk factors. An Lp-PLA₂ >200 ng/mL warrants reclassification of the moderate-risk patient as high cardiovascular risk and should prompt reduction of the low-density lipoprotein cholesterol (LDL-C) target from <130 mg/dL to <100 mg/dL (1 mg/dL = 0.02586 mmol/L). Similarly, patients with coronary artery disease (CAD) or CAD risk equivalents may be considered at very high risk when Lp-PLA₂ is elevated, warranting reduction in the LDL-C target from <100 mg/dL to <70 mg/dL. The panel expands the definition of CAD risk equivalent from the original Adult Treatment Panel III (ATP III) definition, based on current evidence. *Suggested frequency of Lp-PLA₂ testing: measure individuals with Lp-PLA₂ ≤200 ng/mL annually for continued monitoring of risk classification. CV = cardiovascular; HDL = high-density lipoprotein; hs-CRP = high-sensitivity C-reactive protein. TIA = transient ischemic attack. (Adapted from Circulation.)

Event rates plotted against low-density lipoprotein (LDL) cholesterol levels during statin therapy in secondary prevention studies. Once patients are determined to be at high risk for coronary artery disease (CAD), further reduction of LDL cholesterol improves health outcomes, regardless of baseline LDL cholesterol. Therefore, patients at moderate or high cardiovascular risk with elevated lipoprotein-associated phospholipase A₂ will benefit from further LDL cholesterol lowering. Event rates for the HPS, CARE, and LIPID studies are for death from CAD and nonfatal myocardial infarction. Event rates for the 4S and TNT studies also include resuscitation after cardiac arrest. *For cholesterol, 1 mg/dL = 0.02586 mmol/L. 4S = Scandinavian Simvastatin Survival Study; CARE = Cholesterol and Recurrent Events; HPS = Heart Protection Study; LIPID = Long-Term Intervention with Pravastatin in Ischaemic Disease; TNT = Treating to New Targets. (Adapted with permission from N Engl J Med²⁹; Adapted from Lancet, and N Engl J Med.)