Trade-offs on cutpoints for the treatment of hyperlipidemia

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Abstract
Recently, cutpoints defining "abnormal" lipoprotein status have been lowered successively from the 95th to the 90th to the 75th percentile of the general population. To determine what the impact would be, both on those who developed premature coronary artery disease and on the general population, we measured plasma and lipoprotein lipids and low-density lipoprotein (LDL) apolipoprotein B (apo B) in 200 consecutive patients with documented myocardial before the age of 60 years. Defining abnormal as a value for LDL cholesterol above the 95th percentile of the general population "identified" 14% of the cases and 5% of control subjects. Lowering this threshold to the 75th percentile identified a further 26% of cases and 20% of control subjects. The data indicate, therefore, that the incremental value of lowering the cutpoint was small, and thus, while the risk of disease undoubtedly relates to lipoprotein lipids, their limitations in identifying risk within the general population should be recognized. By contrast, the 95th percentile value of the general population for LDL apo B identified 35% of cases as abnormal, a far greater clustering than observed with LDL cholesterol. Measurement of apo B, therefore, should allow more cost-effective delivery of therapy to prevent disease with the general population.