HJAR Nov/Dec 2023

gy that I think will emerge in the years to come will be a reconsideration of the lipid panel it- self. Currently, when we check a lipid panel, it gives us information about total cholesterol, LDL cholesterol, HDL cholesterol — the so called “good” cholesterol — and triglycer- ides. The triglyceride-to-HDL ratio is currently not calculated in these panels but is actually a very good indicator of overall metabolic health and insulin resistance. A ratio of 1-to-1 is ideal, and multiples of that ratio indicate rising levels of insulin resistance and the risk of develop- ing prediabetes or diabetes. Apolipoprotein B is the most atherogenic of all cholesterol particles and probably needs to be routinely measured in everyone. Furthermore, following Apo B levels to monitor therapeutic effective- ness of lipid-lowering therapy is probably even more important than monitoring LDL. The best analogy I’ve heard to describe the difference between LDL and Apo B is to think of your blood vessels as bustling highways. If you are trying to accurately gauge the amount of traf- fic on the road, LDL tells you the total number of passengers, but Apo B tells you the number of cars, which is the more important detail to know. Ten buses with 100 people in each bus may total 1000 people on the highway but will not cause nearly as much traffic as 1000 cars with one person in each car. Apo B levels <40 are ideal when attempting to minimize the chance of any residual cardiovascular risk, and I suspect we are currently only achieving that goal in a very small percentage of patients. In short, optimal medical therapy for cardio- vascular disease encompasses a set of reliably applied, up-to-date, evidence-driven, noninva- sive treatments that have the potential to drive significant improvements in health outcomes while also reducing total cost of care, the es- sence of high-value care. The future of treating cardiovascular disease is full of promise and hope, but to realize it fully, we will have to let go of the notion that stents are better than statins and the rest of optimal medical therapy. We will also have to let go of the economic models that allow low-value care to indefinitely persist. Failure to do so will only exacerbate our current predicament of paying too much for health- care and getting too little in return for it. n Another new agent is inclisiran (Leqvio), which belongs to a novel class known as PCSK9- interfering mRNA agents. Like PCSK9 inhibi- tors, it is an injectable medication that is very potent, capable of lowering LDL by 50%. It also has the potential to lower lipoprotein (a), an additional biomarker correlated with addi- tional cardiovascular risk. European guidelines are ahead of us when it comes to lipoprotein (a) because they recommend checking a base- line lipoprotein (a) in everyone, something not commonly done in standard primary care. That is because two patients with the same LDL can have very different risk profiles for vascu- lar disease depending on their lipoprotein (a) level. Statins do not lower lipoprotein (a), but inclisiran and the PCSK9 inhibitors do. There is also a new drug known as pelicarsen, which is currently undergoing phase 3 clinical trials and is not yet commercially available but has the potential to lower lipoprotein (a) levels by 80%. I suspect that subsequent iterations of our own national lipid guidelines will advise provid- ers to check lipoprotein (a) levels in everyone. An important advance in the field of lipidolo- “If we doctors expect that patients should just trust us and do what we recommend because of our education and advanced degrees, then we fundamentally don’t understand the nature of trust.” HEALTHCARE JOURNAL OF ARKANSAS I  NOV / DEC 2023 27