Choosing Wisely:

Don’t routinely order expanded lipid panels (particle sizing, nuclear magnetic resonance) as screening tests for cardiovascular disease.

Rationale and Comments: A standard lipid profile includes total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and triglycerides. These lipids are carried within lipoprotein particles that are heterogeneous in size, density, charge, core lipid composition, specific apolipoproteins, and function. A variety of lipoprotein assays have been developed that subfractionate lipoprotein particles according to some of these properties such as size, density or charge. However, selection of these lipoprotein assays for improving assessment of risk of cardiovascular disease and guiding lipid-lowering therapies should be on an individualized basis for intermediate- to high-risk patients only. They are not indicated for population based cardiovascular risk screening. Research evaluating the frequency and correlates of repeat lipid testing in patients with coronary heart disease demonstrates that individuals with low-density lipoprotein cholesterol levels of less than 100 mg/dL had no additional benefit from the intensification of lipid-lowering therapies. Understanding the frequency and correlates of redundant lipid testing could identify areas for quality improvement initiatives aimed at improving the efficiency of cholesterol care in patients with coronary heart disease. Millions of U.S. adults are at increased arteriosclerotic cardiovascular disease risk—some because they have had an arteriosclerotic cardiovascular disease event, others because of arteriosclerotic cardiovascular disease risk factors. Adherence to healthy lifestyle behaviors, control of blood pressure and diabetes, and avoidance of smoking are recommended for all adults. Statin therapy should be used to reduce arteriosclerotic cardiovascular disease risk in individuals likely to have a clear net benefit (those with clinical arteriosclerotic cardiovascular disease) or in primary prevention for adults with low-density lipoprotein cholesterol levels over 190 mg/dL, those aged 40 to 75 years with diabetes, and those with a 10-year arteriosclerotic cardiovascular disease risk of 7.5% without diabetes. A clinician–patient discussion that considers potential arteriosclerotic cardiovascular disease risk reduction, adverse effects, and patient preferences is needed to decide whether to initiate statin therapy, especially in lower-risk primary prevention.
Sponsoring Organizations:
  • American Society for Clinical Pathology
  • Sources:
  • Expert consensus
  • Disciplines:
  • Cardiovascular
  • Preventive Medicine
  • References: • Mark McConnell, John R. Downes, Chester B. Good. Decrease the incentives to order lipid panels. JAMA Intern Med. 2014; 174(3):473. doi:10.1001/jamainternmed,2013.12872.
    • Stone NJ, Robinson JG, Lichtenstein AH, Goff DC, et al. Treatment of blood cholesterol to reduce atherosclerotic cardiovascular disease risk in adults: synopsis of the 2013 American College of Cardiology/American Heart Association Cholesterol Guideline. Ann Intern Med. 2014; 160: 339-343.
    • Stone NJ, Robinson JG, Lichtenstein AH, BaireyMerz CN, et al. 2013 ACA/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Accessed September 11, 2014.
    • Sulkes D, Brown BG, Krauss RM, Segrest JP, et al. The editor’s roundtable: expanded versus standard lipid panels in assessing and managing cardiovascular risk. The American Journal of Cardiology, 15 March 2008; 101(6): 828-842.
    • Virani SS, Woodard LD, Wang D, Chitwood SS, et al. Correlates of repeat lipid testing in patients with coronary heart disease. JAMA Intern Med. 2013; 12 Aug:173(15):1439-44.

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