Original Article: The Adult Well-Male Examination
Issue Date: December 15, 2018
See additional reader comments at: https://www.aafp.org/afp/2018/1215/p729.html
To the Editor: In this article, Dr. Heidelbaugh describes a fasting lipid profile as the preferred screening test for assessing cardiovascular risk. This is not correct and should be updated to reflect current guidance. Nonfasting samples are more convenient for patients, and there is no appreciable difference between fasting and nonfasting results for total cholesterol or high-density lipoprotein cholesterol. Because these are the parameters that are used to assess cardiovascular risk, a fasting lipid profile should not be called “preferred.”
The article cites the National Cholesterol Education Panel guidance from 2001 and the U.S. Preventive Services Task Force guideline on statin use for the primary prevention of cardiovascular disease from 2016. The article acknowledges that nonfasting total cholesterol and high-density lipoprotein cholesterol are sufficient for using most cardiovascular risk calculators, but the article is clear in both the text and Table 3 that fasting is preferred. Recommendations from the National Institute for Health and Care Excellence,1 Canadian Cardiovascular Society,2 and American College of Cardiology/American Heart Association3 all consider a nonfasting test to be an equal alternative to a fasting test for screening unless the patient is known to have significantly elevated triglycerides. I was unable to find any support in the 2016 U.S. Preventive Services Task Force guideline for the claim that fasting is preferred.4
I could not help but be struck by the irony that in the very same issue of American Family Physician, there was an editorial regarding the slow adoption of evidence-based practice.5 The authors cited the continued use of fasting lipid profiles, rather than nonfasting testing, as one of the examples of practice changes that have not been widely adopted. They note that “measurement of nonfasting lipids is a more accurate predictor of cardiovascular risk.”5 Their editorial could not have been more timely.
In Reply: Many thanks to Dr. Ehrlich for his thoughtful and referenced discussion regarding fasting vs. nonfasting lipid panels to assess cardiovascular risk. His arguments are acknowledged, and I agree that either fasting or nonfasting lipids are acceptable for this purpose.