132. Lipids: LDL Physiology & Function with Dr. Peter Toth

CardioNerds Academy Chief Fellows Dr. Rick Ferraro (FIT, Johns Hopkins) and Dr. Tommy Das (FIT, Cleveland Clinic) join Academy fellow Dr. Jessie Holtzman (soon, chief resident at UCSF internal medicine residency) to learn all about LDL physiology and function from Dr. Peter Toth! Low-density lipoprotein cholesterol (LDL-C) has been well established as a risk factor for atherosclerotic cardiovascular disease with an ever growing armamentarium of medications to lower LDL-C plasma levels. Yet, LDL-C also plays a number of key physiologic roles across mammalian species, such as cell membrane formation, bile acid synthesis, and steroid hormone production. In this episode, we discuss the definitions of high, normal, low, and ultra-low LDL-C, what functional assays are used to measure LDL-C, and what is considered the safe lower-limit of LDL-C, if there is one at all. Drawing upon experience from rare genetic conditions including abetalipoproteinemia and loss-of-function variants of the PCSK9 gene, we glean pearls that clarify the risks and benefits of low LDL-C. Relevant disclosure: Dr. Toth has served as a consultant to Amarin, Amgen, Kowa, Resverlogix, and Theravance; and has served on the Speakers Bureau for Amarin, Amgen, Esperion, and Novo Nordisk. Pearls • Quotables • Notes • References • Guest Profiles • Production Team CardioNerds Lipid Series PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Pearls 1. Lipoproteins are processed via two major pathways in mammals: 1) exogenous fat metabolism that digests ingested lipids and 2) endogenous fat metabolism that synthesizes lipids in the liver and small intestine. High density lipoprotein (HDL)-mediated reverse transport also brings lipids from the periphery back to the liver. 2. LDL-C comprises ~70% of plasma cholesterol due to its long half-life of 2-3 days. It is one of 5 major lipid particles in plasma including chylomicrons, very low-density lipoproteins (VLDL), intermediate-density lipoproteins (IDL), LDL, and HDL. The liver degrades 40-60% of LDL, while no other tissues in the body make up more than 10% of LDL. LDL-C is energy-poor and cholesterol rich, such that peripheral tissues may not utilize these particles as a fuel source. 3. Preserved functions of LDL-C across mammalian species include cell membrane formation, bile acid synthesis, and steroid hormone production. In other mammalian species, LDL-C levels are found in the 35-50 mg/dL range (Way lower than found in the general human population, and likely more representative of baseline human physiology!). 4. Large, randomized control trials do not consistently demonstrate major adverse effects associated with lower serum LDL-C levels, including risks of cognitive decline, hemorrhagic stroke, reduced bone density, or impaired immune function. 5. Initiation of, and education on LDL-lowering therapy remains insufficient, both in terms of long-term adherence to therapy and achieving current guideline directed goals of LDL-C 150mg/dL).All measurement equations are measured against the gold standard of direct measurement via preparative ultracentrifugation, though this method is far more costly and time intensive. This method is preferred with triglycerides >400 mg/dL, where estimates become less accurate.Non-fasting cholesterol measurements may be more reflective of the “real-world” state as patients are most often post-prandial throughout the day, and are generally recommended as reliable lipoprotein measurement per recent guidelines (the two major exceptions being those undergoing evaluation with a family history of premature cardiovascular disease, and those having eaten a very high-fat meal in the previous 8 hours). 4. How low of an LDL-C is still considered safe? What adverse effects are associated with lower LDL-C levels? As above, recent evidence supports lowering LDL-C to <70 mg/dL in those at high cardiovascular risk, <55 mg/dL in those at very high cardiovascular risk, and even <40 mg/dL in those with a repeat cardiovascular event within two years based on recent U.S. and European Guidelines.The Fourier Trial compared LDL cholesterol reduction with a PCSK9 monoclonal antibody vs placebo and found a 59% reduction from baseline to a median of 30 mg/dL There was no statistically significant difference in adverse events (apart from injection site reactions) in individuals with ultra-low LDL.There is no lower limit of LDL cholesterol that is known to be unsafe. Meta-analyses of primary prevention data demonstrate a linear relationship between LDL-C and ischemic coronary event, so the prevailing philosophy currently remains – when it comes to LDL-C, lower is better.Modern studies have suggested that lower LDL-C is not associated with risk of increased cognitive impairment or hemorrhagic stroke. The ODYSSEY trial in 2019 demonstrated that for patients with recent ACS and dyslipidemia, PCSK-9 therapy decreased the risk of stroke, regardless of LDL-C levels achieved. The PROSPER trial additionally did not demonstrate any significant difference in cognitive function with statin therapy.There is currently no RCT data to suggest impaired immune function or bone density associated with lipid lower therapy. In fact,