Fasting or Nonfasting Lipid Measurements It Depends on the Question

Steven L. Driver, MD, MPH; Seth S. Martin, MD, MHS; Ty J. Gluckman, MD; Julie M. Clary, MD; Roger S. Blumenthal, MD; Neil J. Stone, MD

Disclosures

J Am Coll Cardiol. 2016;67(10):1227-1234. 

In This Article

Abstract and Introduction

Abstract

In the 2013 American College of Cardiology (ACC)/American Heart Association Guideline (AHA) on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults, low-density lipoprotein cholesterol treatment thresholds have been replaced with a focus on global risk. In this context, we re-examine the need for fasting lipid measurements in various clinical scenarios including estimating initial risk for atherosclerotic cardiovascular disease in a primary prevention patient; screening for familial lipid disorders in a patient with a strong family history of premature atherosclerotic cardiovascular disease or genetic dyslipidemia; clarifying a diagnosis of metabolic syndrome so it can be used to make lifestyle counseling more effective; assessing residual risk in a treated patient; diagnosing and treating patients with suspected hypertriglyceridemic pancreatitis; or diagnosing hypertriglyceridemia in patients who require therapy for other conditions that may further elevate triglycerides. Posing a specific question can aid the clinician in understanding when fasting lipids are needed and when nonfasting lipids are adequate.

Introduction

The 2013 American College of Cardiology (ACC)/American Heart Association (AHA) Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults[1] focused attention on risk-benefit profiles of specific classes of lipid drugs, as demonstrated by randomized controlled trials. By emphasizing a patient's global risk for atherosclerotic cardiovascular disease (ASCVD) and identifying groups that benefit from statin therapy, the guidelines took a step forward toward more personalized treatment decisions. In this light, we re-examine the need for fasting lipid and lipoprotein measurements in various clinical scenarios. We contend that for the clinician, choosing between fasting and nonfasting lipids will require careful consideration of the specific question that is posed.

Consider the following case: Mr. Jones is a 40-year-old man, newly insured under the Affordable Care Act, who purchased a bronze-level plan on his state-run exchange. With this new access to care, Mr. Jones' wife convinced her otherwise reluctant husband to make an appointment with you. He is scheduled to see you on a Friday afternoon at 4:00 PM. In advance of his visit, he informs the office staff that he is concerned about missing extra work, high cost-sharing for laboratory tests, and the potential inconvenience of prolonged fasting before his afternoon visit. Your nurse leaves a message for you asking if you would like Mr. Jones to obtain a fasting lipid panel with the upcoming visit. What is the best answer?

Rather than focusing on the "best" answer, we suggest it is more important to first think carefully about what question is to be answered with the results. Different questions arise depending on the given clinical scenario: 1) estimating initial risk for ASCVD in the typical primary prevention patient; 2) screening for familial hypercholesterolemia in a patient with a strong family history of premature ASCVD or other genetic dyslipidemia; 3) attempting to clarify a diagnosis of metabolic syndrome; 4) assessing residual risk in a treated patient; 5) diagnosing and treating patients with suspected hypertriglyceridemic pancreatitis; or 6) diagnosing hypertriglyceridemia (Central Illustration). The best answer to the question of whether the patient should be fasting or not will vary according to the clinical scenarios presented here.

Central Illustration.

The Necessity of Fasting for Lipid Measurements: Summary of Clinical Scenarios and Fasting Requirements
The 6 questions discussed in this review and the recommendations for fasting or nonfasting lipid measurements for each scenario are presented. *ApoB optional, very helpful for precise diagnosis. †In emergency situations, patients with suspected pancreatitis may be assessed with nonfasting lipids. ApoB = apolipoprotein B; ASCVD = atherosclerotic cardiovascular disease.

Comments

3090D553-9492-4563-8681-AD288FA52ACE

processing....