Triglicéridos, colesterol HDL y dislipidemia aterogénica en la guía europea para el control de las dislipidemias 2019 / Triglycerides, HDL cholesterol and atherogenic dyslipidaemia in the 2019 European guidelines for the management of dyslipidaemias

En general, las guías de práctica clínica tanto europeas con americanas han abordado el control de la dislipidemia aterogénica de forma poco convincente e incluso superficial, en gran medida por las limitaciones terapéuticas disponibles. En consecuencia, esta dislipidemia está infradiagnosticada, infratratada e infracontrolada. Dada la reciente aparición de la guía 2019 de la European Atherosclerosis Society y de la European Society of Cardiology sobre el control de las dislipidemias, parece oportuno examinar su posicionamiento con respecto a la dislipidemia aterogénica y/o sus principales componentes, el aumento en las lipoproteínas ricas en triglicéridos y la disminución del colesterol de las lipoproteínas de alta densidad

In general, both European and American clinical guidelines have addressed the management of atherogenic dyslipidaemia in an unconvincing and even superficial way, largely because of the available therapeutic limitations. Consequently, this type of dyslipidaemia is underdiagnosed, under-treated, and under-controlled. Given the recent presentation of the 2019 guidelines of the European Atherosclerosis Society and the European Society of Cardiology on the management of dyslipidaemias, it seems appropriate to examine its position with respect to atherogenic dyslipidaemia and/or its main components, the increase in triglyceride-rich lipoproteins, and the decrease of high-density lipoprotein cholesterol

Selection, preparation, and characterization of commutable frozen human serum pools as potential secondary reference materials for lipid and apolipoprotein measurements: study within the framework of the Dutch project "Calibration 2000".

BACKGROUND: The Dutch project "Calibration 2000" aims at harmonization of laboratory results via calibration by development of matrix-based secondary reference materials. We considered the selection, preparation, and characterization of 34 potential reference materials (PRMs). METHODS: Sixteen PRMs were prepared either strictly according to the NCCLS C37-A protocol or in a less stringent and more convenient way. In addition, 18 commercial, so-called human serum-based calibrators or controls were purchased and tested. Lipoprotein integrity was evaluated by examining the physicochemical characteristics of the materials. Commutability of the PRMs was assessed in 86 Dutch clinical laboratories, using a multicenter split-patient-sample between-field-method (twin-study) design. Normalized residuals of the PRMs with respect to the patient regression lines were calculated; in addition, the extra contribution of each PRM to the total measurement uncertainty (CV(Netto)) was calculated. On the basis of these results, the most native PRM was selected to investigate its potential to reduce interlaboratory variation and to improve lipid and apolipoprotein standardization. RESULTS: In general, only the NCCLS C37-A-type materials displayed normalized residuals below the decision limit for commutability and had small CV(Netto) values ranging between 0 and 3.8%. This contrasts with the findings in regularly pooled frozen sera and lyophilized cryoprotected PRMs. In two subsequent external quality assessment surveys, the NCCLS type C37-A materials contributed to reducing the intermethod lipid and (apo)lipoprotein variation to approximately 2-4%. CONCLUSIONS: NCCLS C37-A materials have a strong potential as secondary reference materials, not only for cholesterol but also for HDL-cholesterol, LDL-cholesterol, triglyceride, and apolipoprotein measurements.

Laboratory standardization of a large international clinical trial: the DAIS experience. DAIS Project Group. Diabetes Atherosclerosis Intervention Study.

OBJECTIVE: To implement a quality control program for the standardization and harmonization of lipid and lipoprotein analyses as performed at two core laboratories (St. Paul's Hospital, UBC [Vancouver], and NPHI [Helsinki]) for the Diabetes Atherosclerosis Intervention Study (DAIS). DESIGN AND METHODS: A DAISSOFT computer program was designed to minimize the occurrence of data and sample management errors during the course of the study. Fresh human serum was used for the provision of an accuracy based external quality control program that monitored the analytical performance of lipid testing at these two laboratories. A separate program was designed for monitoring hemoglobin A1c (HbA1c). At the outset of the study, allowable total error goals were established for each analyte. Ongoing performance was monitored using bimonthly blinded challenges of fresh human serum. The two EQA programs routinely monitored the analysis of total cholesterol, calculated LDL-cholesterol, HDL-cholesterol, net triglycerides, apoprotein A-1, apoprotein B, and HbA1c. RESULTS: The EQA precision and accuracy data for the measurement of total cholesterol at the two core laboratories over the last 5 years indicated both laboratories operated with good precision, approximately 1% CV over the time period. The accuracy at both laboratories was similar initially. Part way through the study, the accuracy of the cholesterol method at NHPI tended to drift upward with an operating positive bias (+3%) relative to the Abell Kendall reference method. Triglyceride measurements were the most problematic for the study. By EQA cycle 8, the accuracy of the method at UBC had stabilized and was meeting the accuracy goals of the study. NPHI's method was negatively biased relative to the accuracy base of the DAIS study. In spite of recalibrating their method, NPHI found it difficult to maintain consistent accuracy for the measurement of triglycerides during the study. Both laboratories operated their HDL methods with excellent precision. Accuracy at NHPI was well maintained over the course of the study whereas the accuracy of HDL measurements at UBC was more problematic. There was an inconsistent variation in the accuracy of apoprotein A-1 measurements at both laboratories. In most cases, the bias would be corrected by the time of the next EQA challenge. In the case of apo B, one laboratory was standardized to the CDC while the other laboratory was standardized to IFCC/WHO. The discrepancy between these two accuracy bases was >20%. Recalibration to a common accuracy base rectified the problem. Only minor problems were encountered with the precision and accuracy of the DIAMAT assay for hemoglobin A-1c. The two DAIS core laboratories consistently operated within the 9% total error goals of the study for HbA1c. CONCLUSIONS: Through the use of this program, the two DAIS core laboratories were able to maintain their lipid analyses within the limits of allowable total error that had been established for the study.

Apolipoprotein B and A-I values in 147576 Swedish males and females, standardized according to the World Health Organization-International Federation of Clinical Chemistry First International Reference Materials.

Serum concentrations of apolipoprotein (apo) B and apo A-I were measured from 1985-1996 in a Swedish population sample of 83 112 males and 64 464 females, ages <20 to >80 years, using an automated immunoturbidimetric method calibrated against fresh pools of human serum and commercial calibrators. All values were recalculated in 1997 after calibration against the WHO-IFCC First International Reference Materials. The recalculation factor was 1.059 for apo B, whereas for apo A-I, the correction was: y = 0.989x + 0.101. The total CVs for both apo B and A-I were generally <7%. The mean value (+/- SD) for apo B was 1.31 +/- 0.35 g/L in all males and 1.22 +/- 0.36 g/L in all females. The mean apo A-I concentration was 1.36 +/- 0.22 g/L in males-10% lower than in females (1.51 +/- 0.24 g/L). The mean value of apo B increased up to 60 years of age in males and up to 70 years of age in females. apo A-I concentrations changed only slightly with age in both males and females. apo A-I concentrations among Swedes are nearly identical to those reported recently by two American studies and those obtained in a Finnish population sample. Mean apo B concentrations differ somewhat between the populations but mirror-as expected-differences in total cholesterol concentrations. The highest values were noted in Swedish subjects. The Swedish sample population is, to our knowledge, the largest describing the distribution of apo B and A-I in a general population of adult males and females of all ages determined with procedures standardized and traceable to the WHO-IFCC First International Reference Materials.

[Reference values of apolipoproteins A1 and B. Contribution of international standardization. Travail collaboratif entre la SFBC, l'Arcol et le SFRL]. / Valeurs de référence des apolipoprotéines A1 et B. Apport de la standardisation internationale. Travail collaboratif entre la SFBC, l'Arcol et le SFRL.

The utilization of two WHO reference materials, liquid and lyophilized, permitted international standardization of apolipoprotein measurements. We report here the results of a collaborative study between Arcol, SFBC and SFRL in order to establish reference ranges for apo A1 and B on nine standardized systems. A population of 1027 men and women supposed healthy, 4 to 60 year old, have been selected in two Centers for Preventive Medicine. The serum samples were aliquoted frozen at -20 degrees C the day of sampling and analysed by the manufacturers with IFCC standardized calibrants. A specific quality control was performed using a frozen pool of sera. For apo A1, the centile 2.5 of the reference population varies from 1.04 to 1.16 g/l. The range values for the centile 97.5 varies from 1.87 to 2.24 g/l. For apoB, the centile 2.5 varies from 0.43 to 0.57 g/l, and the centile 97.5 from 1.30 to 1.39 g/l. Only one system has a problem of dispersion with an upper limit equal to 1.20 g/l. These results improve that international standardization allowed actually a good comparability of the results, especially for apoB.

Reference limits of apolipoprotein A-I and apolipoprotein B using an IFCC standardized immunonephelometric method.

An important collaborative study organized by the IFCC enabled the selection of international reference materials and the standardization of commercially available methods by the use of common calibrators. In this paper, we report the reference limits of apolipoprotein A-I and apolipoprotein B in a selected healthy French population. The apolipoprotein measurements were performed on BNA Behring using reagents and protocols supplied by the manufacturer: the standard sera were calibrated using the IFCC-WHO reference preparations (SP1 and SP3). In addition, the apolipoprotein B protocol was modified by the addition of a supplementary reagent to reduce the interference by lipaemic samples on immunonephelometric measurement. In a sample of 115 random serum samples, there was a decrease in mean concentration between non-standardized and standardized methods: -4.8% for apolipoprotein A-I and -4.7% for apolipoprotein B. The reference limits for apolipoprotein A-I are unaffected by gender between 4 and 14 years, thereafter vary with age and gender until 40 years and with gender alone between 40 and 60 years. For apolipoprotein B, the variation with gender is only significant between 30 and 49 years.

Standardization of Lp(a) measurements.

Two direct binding ELISAs were developed in our laboratory for measuring Lp(a) in human plasma. The first ELISA was performed by using a monoclonal antibody to apo(a) bound to the solid phase and a second monoclonal antibody to apo(a) as detecting antibody. The second ELISA was performed by using the same monoclonal antibody bound to the solid phase and an anti-apo B polyclonal antibody as detecting antibody. The immunoreactivity of Lp(a) particles of different size, isolated from subjects with F, B or S2 isoform, were evaluated by the two ELISA methods. Superimposable standard curves were obtained by the three Lp(a) preparations when using the apo(a) detection system, but the Lp(a) containing the largest apo(a) isoform S2 had a significantly reduced slope by the apo B detection method. Lp(a) concentration was determined in plasma samples by the two ELISA methods. When Lp(a) with apo(a) isoform S2 was used to calibrate the assays, similar Lp(a) values were obtained by the two different detecting systems on samples from subjects with isoforms S2, S3 or S4, while values in the samples with B and S1 isoforms were significantly higher. When Lp(a) with isoform B was used as calibrator, comparable Lp(a) values were obtained by the two methods on samples with B isoform, while the values were lower in the samples with the higher molecular weight isoforms when measured by the apo B detection method. A pilot study was conducted to evaluate Lp(a) values obtained by different methods calibrated with a common fresh-frozen serum with a defined apo(a) isoform.(ABSTRACT TRUNCATED AT 250 WORDS)

Enzyme-linked immunosorbent assay to measure apolipoproteins AI and B secreted by a human hepatic carcinoma cell line (Hep G2).

We describe an enzyme-linked immunosorbent assay (ELISA) to measure apolipoproteins AI and B secreted by Hep G2 cells and in cell homogenates. These assays utilize commercially available polyclonal antibodies, affinity-purified to improve their specificity, thereby achieving a dramatic increase in the sensitivity of the assay. These affinity-purified antibodies were also more sensitive than a series of monoclonal antibodies tested. We achieved a sensitivity of 0.4 ng in the apo AI assay, and a sensitivity of 5 ng in the apo B assay. By these methods, we measured secretion rates by Hep G2 cells of 358 +/- 41 ng/mg cell protein/hr for apo B and 137 +/- 8 ng/mg cell protein/hr for apo AI. These assays also allowed the measurement of intracellular apolipoproteins and thus can be used to facilitate investigations of human lipoprotein metabolism in cell culture systems.

Effects of analytical method and lyophilized sera on measurements of apolipoproteins A-I and B: an international survey.

In 1987 a collaborative study was initiated with 140 laboratories worldwide to evaluate the effects of analytical method and lyophilization on the measurement of different concentrations of apolipoproteins (apo) A-I and B in four lyophilized serum pool samples. This survey confirmed that the lyophilized apo Reference Material of the International Union of Immunological Societies (IUIS) is useful for apo A-I assays as an international serum-based reference material, because among-method variation is negligible. The apo A-I concentration value of 1.24 g/L is now assigned to the IUIS Reference Material (CDC 1883) by a Centers for Disease Control RIA in-house reference method. Use of lyophilized serum preparation as a reference material for some modes of apo B measurement is questionable because of lyophilization and matrix effects. Both radial immunodiffusion and liquid immunoprecipitin methods demonstrated bias in measured apo B concentrations, compared with overall method-weighted means values on the IUIS Reference Material. Because of the uncertainty associated with LDL primary standard, protein analysis, and concentration differences among analytical methods, assigning a single apo B concentration value to the IUIS Reference Material appears inadvisable at present.

Effects of lyophilization of serum on the measurement of apolipoproteins A-I and B.

A common accuracy-based standardization program is indispensable for establishing reference intervals for the clinical use of apolipoproteins. The development and distribution of reference materials and quality-control materials that do not exhibit matrix effects between methods is essential to the standardization process. We examined the suitability of lyophilized material as a common reference material for the measurement of apolipoproteins A-I and B. We determined values for apolipoproteins A-I and B in frozen and lyophilized serum pools, using different immunochemical approaches. We found little or no differences in apolipoprotein A-I values between frozen and lyophilized pools as determined by the different methods. In contrast, values for apolipoprotein B in lyophilized samples were consistently lower than those obtained for frozen samples. After adjusting for the effect of dilution due to reconstitution, the difference in the apolipoprotein B values for lyophilized as compared with frozen samples ranged from -26% to 4%, depending upon the assay method. Evidently, serum pools in lyophilized from are not a suitable matrix for reference materials for apolipoprotein B measurements but can be used for apolipoprotein A-I measurements.

Evaluation of a monoclonal antibody-based enzyme-linked immunosorbent assay as a candidate reference method for the measurement of apolipoprotein B-100.

A monoclonal antibody-based direct binding enzyme-linked immunosorbent assay (ELISA) for apoprotein (apo) B-100 has been developed for use as a reference method. The assay uses the two well-characterized monoclonal antibodies, MB24 and MB47. MB47, which recognizes an epitope at the low density lipoprotein (LDL) receptor-binding domain of apoB and is specific for apoB-100, is bound to the microtiter plate as the capture antibody. MB24, which binds an epitope in the amino terminal half of the apoB-100 and identifies both apoB-100 and apoB-48, is conjugated to horseradish peroxidase and is utilized as the indicating antibody. The assay was calibrated with LDL (d 1.030-1.050 g/ml) and the LDL protein was determined by a sodium dodecyl sulfate (SDS) Lowry procedure. The working range of the assay is 0.25-1.25 micrograms/ml. Optimal dilution of whole plasma was found to be 1:2000. In the assay, MB47 bound approximately 97% of the apoB in all low density lipoprotein, and greater than 90% of the apoB in the majority of very low density lipoprotein preparations. Small dense LDL from subjects with familial combined hyperlipidemia (FCHL) and large bouyant LDL from subjects with familial hypercholesterolemia (FH) exhibited binding properties similar to LDL from healthy normolipidemic subjects when tested in the reference ELISA. The intra- and interassay coefficients of variation averaged 2.5% and 6.0%, respectively. Plasma B-100 levels were not influenced by freezing and thawing or storage at 4 degrees C for up to 3 weeks or storage at -70 degrees C for up to 11 months. Excellent agreement was obtained between the reference ELISA and a polyclonal RIA which measures total apoB (r = 0.93, n = 105, mean ELISA B-100 value = 100 mg/dl, mean RIA value = 101 mg/dl, Sy = 9.6). Reference ELISA B-100 values of samples pretreated with bacterial lipase were not significantly increased in most samples with plasma triglyceride levels below 600 mg/dl. To help reduce the large among-laboratories variability of apoB measurements, we recommend that this candidate reference direct binding ELISA be used to assign apoB target values to apoB reference pools.

Standardization of apolipoprotein B and A-I measurements.

Apolipoprotein B, the major protein of low-density lipoprotein, and apolipoprotein A-I, the major protein of high-density lipoprotein, can serve as important predictors of atherosclerotic cardiovascular disease. However, these apolipoprotein measurements have not realized their full potential because of inadequate standardization. Purified apolipoprotein A-I of known absolute mass, in lyophilized form, can serve as primary standard for apolipoprotein A-I, and freshly isolated low-density lipoprotein of narrow density range can serve as primary standard for apolipoprotein B. These primary standards can be used to assign target values to secondary reference material and calibrators by reference laboratories using standardized, validated immunoassay procedures. Lyophilized serum can serve as secondary reference material for apolipoprotein A-I. Freshly frozen serum pools should be used as reference material for apolipoprotein B until more practicable materials that do not exhibit matrix interactions are developed. Implementation of proper standardization procedures can lead to significant improvements in apolipoprotein measurements.

An international collaborative study on standardization of apolipoproteins A-I and B. Part I. Evaluation of a lyophilized candidate reference and calibration material.

We evaluated a lyophilized serum preparation for use as a candidate Reference Material for apolipoproteins (apo) A-I and B. An international collaborative study was conducted with 28 participating laboratories, selected on the basis of participation and demonstrated expertise in a 1983 survey of apolipoproteins A-I and B. The analytical suitability of the material was established by confirming linearity of its dose-response curves over a desired concentration range and demonstrating that its response curves paralleled those for fresh sera. Differences in dilution-adjusted mass units ascribable to the five analytical methods used by the various laboratories constituted only 1% of the total variation for apo A-I, but 32% for apo B. The dominant source of error, however, for both apo A-I and B was the variability among laboratories, rather than variability among methods and antisera. The assigned consensus mass-concentration units based on study data are 1.124 g/L for apo A-I, 0.589 g/L for apo B. For these estimates the coefficients of variation were 13% and 27%, respectively. These findings on the proposed Reference Material meet the requirements suggested by the World Health Organization's Expert Committee on Biological Standards for a candidate WHO Reference Preparation.

An international collaborative study on standardization of apolipoproteins A-I and B. Part II. Evaluation of contributions of antisera to among-laboratory variance components.

Local antisera (LA) were compared with a common interim reference antiserum (IRA) to examine the antiserum component of the among-laboratory variation in an international collaborative study with 28 laboratories evaluating a candidate international Reference Material (apo-RM) for apolipoproteins A-I (apo A-I) and B (apo B). Measurement of the relative concentration of lyophilized preparations differed by less than 1% for LA and IRA. The percentage of the total variation in measurement of the concentration of apo-RM that was contributed by antisera among laboratories was 5% and 8% for apo A-I and B, respectively. Estimated differences from overall mean concentrations for the five different immuno-methods were greater for apo B (range: +22% to -23.5%) than for apo A-I (range +14% to -14%), but were similar within a method for LA and IRA. The results indicated that antisera are not a major source of error among laboratories and, indeed, are responsible for relatively little of the total variability.

VLDL apolipoprotein B determination in blood serum following precipitation of LDL with polyvinylsulphate.

A method is described for the determination of VLDL apolipoprotein B by radial immunodiffusion (RID) in serum supernatants following precipitation of LDL with polyvinylsulphate. The measurement of VLDL apolipoprotein B is based on the incubation of the polyvinylsulphate supernatant with triglyceride lipase (330 kU/l end concentration) for 12-24 hours at 37 degrees C. A good measure of agreement was found for the corresponding VLDL apolipoprotein B values measured by RID in the polyvinylsulphate supernatants (y) and VLDL apolipoprotein B values calculated as tetramethylurea-insoluble protein in the d less than 1.006 kg/l serum fraction (x) (r = 0.88, y = 0.96x + 0.004, n = 54). Within the tested range of 1.2 mmol/l to 6.7 mmol/l triglycerides, the concentration of apolipoprotein B measured in the polyvinylsulphate supernatant showed a linear relationship. Correlation analysis of VLDL apolipoprotein B values and serum triglycerides and VLDL cholesterol, respectively, showed a good correlation (r = 0.77 and r = 0.75, respectively, n = 54). In the determination of VLDL apolipoprotein B measured in polyvinylsulphate supernatant, a variation coefficient of 4.3% (means = 10.1 mmol/l, n = 20) was found in relation to the precision in the series, and a variation coefficient of 11.4% (means = 5.3 mmol/l, n = 15) in relation to day to day precision.