LDL pattern B

Here's a Q&A I stumbled on in the Forum of MedHelp, where people obtain answers from presumed health "experts."


My VAP test results in July 07 identified an LDL Pattern B.
Overall results:
Total 150
HDL 75
LDL 61
Trig 60
HDL-2 17
LP(a) 6.0
LDL Pattern B

Lipitor 10mg
Zetia 10mg
Altace 10mg
Atenolol 50mg
Plavix 75mg
Aspirin 81mg

I had several heart attacks which resulted in CABG performed May 2000. I am a 53 year old white male , 6'1", 190 pounds, exercise every day, watch my diet and feel great. Everything looks OK except my LDL Pattern B. Is there any therapy to improve the Patten B?

Answer from CCF, MD:
Your results indicate an LDL pattern B, which generally indicates small atherogenic LDL particles which may cause increased risk for CAD. However, there are several problems with LDL patterning: 1) its unreliability (of LDL pattern testing ), 2) unclear clinical evidence regarding regarding the usefulness of LDL patterns and particle size. The majority of evidence regarding the progression of atherosclerosis is with LDL lowering and to an smaller extent HDL raising.

All available clinical evidence shows that any particles in the VLDL, IDL, or LDL range are atherogenic, and there is no evidence that whether belonging to pattern A or B one is more atherogenic than others.

Subclass studies have proliferated over the last few years, but many of these studies were funded or subsidized either by suppliers of the assays as a method to expand their use and move them into mainstream practice, or by pharmaceutical companies in an attempt to claim some advantage over other therapeutic agents.
Thus, current data on LDL subclasses are at best incomplete and at worst misleading, suffering from publication bias, and now given the recent results of the Ensign et al. study, unreliable.

Your LDL, and HDL are at goal. The Lpa level is still not clearly linked as a modifiable risk factor for CAD, although elevated levels are now know to be linked to stroke.

Continue with your present treatments: aspirin, plavix, ateonol and altace are all essential medications.

Wow. The extent of ignorance that pervades the ranks of my colleagues is frightening.

Contrary to the response, LDL particle size assays are quite reliable and accurate. I've performed many thousands of lipoprotein assays and they yield reproducible and clinically believable results. For example, eliminate wheat, oats, cornstarch, and sugars and small LDL drops from 2400 nmol/L to 893 nmol/L (NMR)--huge drops. If repeated within a short period of time, the second measure will correspond quite closely.

The data are also quite clear: Small LDL particles (i.e., "pattern B") are a potent predictor of cardiovascular events. What we lack are the treatment trials that show that reduction of small LDL results in reduced cardiovascular events. The reason for this is that small LDL research is not well-funded, since there is no prescription drug to treat small LDL, only nutritional means. Niacin (as Niaspan) is as close as it comes for a "drug" to reduce small LDL. But diet is far more effective.

Given the questioner's fairly favorable BMI of 25.1 and his history of aggressive heart disease, it is virtually certain that he has what I call "genetic small LDL," i.e., small LDL that occur on a genetically-determined basis (likely due to variants of the cholesteryl-ester transfer protein, or CETP, or of hepatic lipase and others).

Ignoring this man's small LDL will, without a doubt, consign him to a future of more heart attacks, stents, and bypass. Maybe by that time the data supporting the treatment of small LDL will become available.

Comments (17) -

  • Ned Kock

    7/18/2010 5:14:33 PM |

    Hi Dr. Davis.

    Indeed, strange advice there. It seems that in terms of effects on arterial stiffness, compared with postprandial glucose levels lipids are not even on the radar screen:


    That is, as you have been pointing out all along, if one "eats to the meter", lipids tend to fall into place. For most people all it takes is to remove refined carbs and sugars from the diet. For others it means to remove some whole foods as well, such as potatoes and bananas.

  • Anonymous

    7/18/2010 6:54:08 PM |

    Dr. Davis- If the person in your post here has genetic small LDL, what are his options? Isn't he kind of stuck? If he lowers his already fairly low LDL too much more, won't he be oversuppressed? Can niacin lower (or convert, or whatever) the small LDL in "genetic" smLDL type, or should such a person just try to get their smLDL particles as low as possible? (even though they might always stay small?)

  • Anonymous

    7/18/2010 8:08:01 PM |

    Dr. Davis,

    What do you look at more, small LDL particles or average LDL size?  Over the period of a year, my small LDL particles have gone down to < 90 nmol/L from around 120 last year, but my average LDL size has decreased (though still pattern A) to 21.1 nanometers (from about 22.3 last year).  


  • Anonymous

    7/19/2010 4:20:01 AM |

    Since it doesn't account for muscle or fat (i.e. athletic or sedentary), I wouldn't think BMI is a very good indicator of anything...

    Perhaps if the original poster had said his BODY FAT % is 25.1% then that can be evaluated as "favorable" or not.

  • Jim Purdy

    7/19/2010 4:26:43 AM |

    "eliminate wheat, oats, cornstarch, and sugars"

    Doctor Davis, based on your many previous posts,  I assume that this is good advice for everybody, not just the individual who asked the question?

  • Christian Wernstedt

    7/19/2010 7:05:11 PM |

    The person's trigs/HDL ratio is 0.8 which ought to indicate large pattern LDL.

    Is the discrepancy with the VAP test because of this person's genetics, or might some other factor be at play?

    Can we generally rely on the trigs/HDL ratio in people who are generally healthy with no signs of the metabolic syndrome?

  • Anonymous

    7/19/2010 11:21:35 PM |

    Christian Wernstedt, I thought that was odd too.  But then again, he is on a boatload of drugs that are designed to manipulate lipid numbers.  You can see that the drugs did indeed give him very low LDL, but seem to have done so by shrinking the particle size, thus the VAP pattern B.  

    So in the case of "great" lipid values here, it would seem they are not so great when achieved artificially by means of drugs.  He may have been better off with "high" cholesterol if it used to be large, fluffy LDL, especially if he had the high HDL and low triglycerides back then too.

  • Onschedule

    7/20/2010 12:35:40 AM |

    Christian Wernstedt,

    The comment Anonymous left is consistent with my experience. My father's LDL was in the 40s under "control" with statins. He died of a heart attack less than a week after passing a stress test. Reviewing his Berkeley lipid tests, he was solid LDL pattern B, though his trigs and HDL were enviable.

  • Anonymous

    7/20/2010 1:37:26 AM |

    i have a question as a neurosurgeon who completely thinks that Cholesterol is immaterial.  Do you Dr Davis as a cardiologist value the VAP or the HS CRP in your practice for true cardiac risk.  All my reading points to HS CRP......I am not sure that the VAP does anything unless you have a genetic predisposition.  Is this correct thinking or not?  Dr. K

  • Dr. William Davis

    7/20/2010 2:16:24 AM |

    Judging from the comments, a lot more conversation on small LDL is in order.

    It's actually quite simple, but the world floods us with misinformation hell bent on leading us towards statins and the small LDL CREATING low-fat diet.

    I will address these issues in forthcoming posts.

  • Peter

    7/20/2010 5:20:44 PM |

    If I want to find out my small particle number what test should I request.

  • Bob

    7/20/2010 8:48:26 PM |

    I am the original poster with the July 2007 blood test results. My April 2010 test results are as follows:
    Total = 129
    HDL = 79
    TRG = <45
    LDL = N/A
    non HDL = 50
    TC/HDL = 1.6

    Same meds 185 lbs.

    Am I killing myself with these numbers?

  • Anonymous

    7/20/2010 11:40:07 PM |

    Do you still have the small LDL pattern?

  • Bob

    7/21/2010 12:01:14 AM |

    Anonymous said...
    Do you still have the small LDL pattern?

    No, I have not had that tested since 2007- a university medical center performed that test and was not worried with the LDL pattern B results. No VAP tests since, only the standard lipid tests.

  • David

    7/21/2010 12:52:55 AM |


    To find out your small LDL particle number, have your doctor order an NMR LipoProfile. You can also order these yourself without a doctor (very inexpensively) from places like privatemdlabs.com. You just order the test online, go to a local blood drawing station at your convenience, and look for the results to be emailed to you in a couple days. That's what I do. Super easy.


  • Philip Barr

    8/2/2010 4:56:45 PM |

    Great thread in this blog. Bob, you have good advice here. I am also a big Niacin enthusiast and often use it in combination with a natural lipid lowering group of supplements: Triplichol + Niacin.
    Regarding your comment last month "Am I killing myself..." . You have to know that you are doing the best you can, and holding a positive mental attitude is extremely important as well. In my mind/body medicine fellowship we taught people stress management as well as doing the exercise and nutrition side. Weaving this into internal medicine has been rewarding.

Cath lab energy costs

Cath lab energy costs

In honor of Earth Day, I thought I'd highlight the unexpectedly high carbon costs of activities in hospitals, specifically the cardiac catheterization laboratory.

A patient enters the cath lab. The groin is shaved using a plastic disposable razor, the site cleaned with a plastic sponge, then the site draped with an 8 ft by 5 ft composite paper and plastic material (to replace the old-fashioned, reusable cloth drapes). A multitude of plastic supplies are loaded onto the utility table, including plastic sheaths to insert into the femoral artery (which comes equipped with a plastic inner cannula and plastic stopcock), a multi-stopcock manifold that allows selective entry or removal of fluids through the sheath, a plastic syringe to inject x-ray dye, plastic tubing to connect all the devices (total of about 5 feet), and multiple plastic catheters (3 for a standard diagnostic catheterization, more if unusual arterial anatomy is encountered).

All these various pieces come packed in elaborate plastic (polyethylene terephthalate or other polymers) containers, which also come encased in cardboard packaging.

Should angioplasty, stenting, or similar procedure be undertaken, then more catheters are required, such as the plastic "guide" catheters that contain a larger internal lumen to allow passage of angioplasty equipment. An additional quantity of tubing is added to the manifold and stopcock apparatus, as well as a plastic Tuohy-Borst valve to permit rapid entry and exit of various devices into the sheath.

Several new packages of cardboard and plastic are opened which contain the angioplasty balloon, packaging which is usually about 4 feet in length. The stent likewise comes packaged in an 18-inch or so long package with its own elaborate cardboard and plastic housing.

At the conclusion of the procedure, another cardboard/plastic package is opened, this one containing the closure device consisting of several pieces of plastic tubes and tabs.

If the procedure is complicated, the number of catheters and devices used can quickly multiply several-fold.

By the conclusion of the procedure, there are usually two large, industrial-sized trash bins packed full of cardboard, plastic packaging, and discarded tubing and catheters. The trash is so plentiful that it is emptied following each and every procedure. None of it is recycled, given the contamination with human body fluids.

That's just one procedure. The amount of trash generated by these procedures is staggering, much of it plastic. I don't know how much of the U.S.'s annual plastic trash burden of 62 billion pounds (source: EPA) originates from the the cath lab, but I suspect it is a big number in total.

So if you are truly interested in reducing your carbon footprint and doing your part to be "green," avoid a trip (or many) to the cath lab.

Comments (6) -

  • Anonymous

    4/23/2009 8:05:00 AM |

    Dr. Davis,
    Isn't a catheter used for an angiogram?  I thought an angiogram is a necessity before surgery for an aortic abdominal aneurysm?  What are the other alternatives if catheters make so much rubbish?  Just wondering since my mother is considering having surgery for her AAA and needs to have an angiogram first.
    Josephine Keliipio

  • Anonymous

    4/23/2009 2:19:00 PM |

    Dr. Davis doesn't answer questions posted to his blog any longer. He announced this some time ago.

    I think the point of his little story about being green is to avoid having to have such a procedure done in the first place. I don't believe he is suggesting that you ask the Hospital to recycle all the left over rubbish from such a procedure. At the rate of pay of those people, they'd probably have to charge you a couple of hundred dollars to sort everything out that could be recycled..  Frown

    I am only a lay person but I believe there is no alternative (less rubbish producing that is) to the procedure your Mom needs done. Don't worry about the trash and focus on your Mom's outcome instead.

    Good luck with your Mom's procedure.

  • Anonymous

    4/23/2009 5:10:00 PM |

    Catheter angiogram is no longer needed to demonstrate arteries, especially arterial anatomy in the abdomen, extremities,head and neck, including, carotids and intracerebral arteries, arteries in the arm or legs. There is now, an alternative, non-invasive. This consist of CT, CTA, or even better, without radiation an MRI,MRA. The only indication for catheter angiogram is if there is plan for angioplasty, or placement of a stent.
    No one or nobody should be subjected, to a catheter angiogram, in this day and age.
    I hope this helps.

  • Jonathan Selwood

    4/23/2009 5:55:00 PM |

    Dr. Davis,

    Much obliged for the post.  It provides me with a wonderful counter to claims that a grain-based diet has less of an environmental impact.

    Wheat=Heart Disease=Medical Waste


  • Anonymous

    4/24/2009 9:41:00 AM |

    Anonymous #2,
    Thanks for your comment about angiograms. I am still learning about this procedure and am glad to know that there may be other alternatives. My mom had no plans for a stent or an angioplasty but it seems that angiograms are the standard for elderly patients electing to fix AAAs. Anyway, lots of questions to ask the cardiologist when we see him again in a few weeks. Josephine

  • jean

    4/25/2009 5:53:00 PM |

    Mmmm...stay out of the surgical ICU also, if you can help it. We generated on average 3-4 large cans of waste per room (14) per shift (12hr) per day. Efforts to separate out recyclables were futile. And let's not even get into hand washing. This was in 2000. I hope things have improved.