Question

Sample A is from a 35 year old male who visited his GP complaining of chest pain during exercise. An ECG taken at rest was normal but ischaemic changes developed on exercise. A family history revealed that his father died of a heart attack at the age of 45 years. The laboratory test results for his fasting blood sample were as follows:

Analyte                       Patient values                        Reference range for fasting

     blood sample

Sodium                                    139                              135-145 mmol/L

Potassium                                4.1                               3.0-5.0 mmol/L

Total protein                           69                                65-80 g/L

Albumin                                  35                                35-47 g/L

Calcium                                  9.3                               9.0-10.5 mg/dl

Lactate dehydrogenase           250                              90-190 IU/L

Creatine kinase                       129                              30-60 IU/L

Asparatate transaminase         70                                < 40 IU/L

Gamma glutamyl transferase 30                                < 50 IU/L

Total Bilirubin                        13                                0.4-15 μmol/L

Glucose                                   12                                3.5-5.5 mmol/L

Fructosamine                          351                              205-285 μmol/L

Cholesterol                             

            Total                            7.2                               <5.2mmol/L

            HDL                            1.4                               >1.5 mmol/L

            LDL                            ?                                  <3.5 mmol/L

Triglycerides                           2.95                             <1.7mmol/L

On the gradient gel electrophoresis, plasma sample for this patient showed the presence of small dense LDL particle.

1. Calculate and comment on the LDL cholesterol values. What does the presence of small dense LDL mean?
2. How many cardiovascular risk factors does this patient have?
3. Discuss the type of hyperlipidaemia this patient is likely to have.
4. What further tests and dietary/drug treatments would you recommend for this patient?

Answer 1

Ans:

• LDL cholesterol = Total cholesterol - HDl cholesterol - (Triglycerides/ 5)

= 7.2 - 1.4 - (2.95/ 5)

= 7.2 - 1.4 - 0.59 = 5.21

So, LDL cholesterol = 5.21 mmol/ L, which is high in comparison to normal reference value i.e. < 3.5 mmol/ L

• Presence of small dense LDL particles (VLDL) on gradient gel electrophoresis considered as an emerging risk factor for cardiovascular disease and atherosclerosis as well.

• The patient is having the following cardiovascular risk factors based on case details:

(i) Family (Father) history of heart attack

(ii) High value of Lactate dehydrogenase

(iii) High value of Creatinine kinase

(iv) High value of Aspartate transaminase

(v) High value of Total cholesterol, LDL cholesterol, and Triglycerides

(vi) Low value of HDL cholesterol

(vii) Presence of small dense LDL particles (VLDL)

• Because of increased presence of Total cholesterol, LDL cholesterol, Triglycerides, and VLDL in patient; therefore, patient is likely to have Type II Combined Hyperlipidemia/ Hypercholesterolemia/ Hypertriglyceridemia.

• No further tests or examination is required, only dietary and drug treatment along with precautionary measures should be needed to follow by the patient.
• Dietary treatment includes: High fibre rich diet like vegetables, fruits, whole grains, poultry, fish and nuts.
• Drug treatment includes: Statins are the drug of choice.