Detecting severe hyperlipidemia in the general population through occupational screening
Lars Andersen, BA, Heidi Testa, BSN, CCRP, Brynn Kline, MEd, Alice Yoder, MSN, Rolf Andersen, MD, FACC, FNLA
Lancaster General Health/Penn Medicine Research Institute
[email protected]
Background
The incidence of severe hyperlipidemia potentially indicative of
familial hypercholesterolemia (FH) in Lancaster County is currently
unknown and may vary from composite national or international
estimates. Individuals with untreated severe hyperlipidemia face
significantly elevated risk of atherosclerotic disease and myocardial
infarction.1,2,3 Whereas countries with nationalized health systems
may draw on large-scale population data not immediately available
in the United States, we sought to examine the utility of occupational
lipid screening instead as a population health tool related to
atherosclerotic risk of possible familial origin.
Hypothesis
Our objective was to estimate the rate of uncontrolled severe
hyperlipidemia (LDL-C ≥ 190 mg/dL) potentially indicative of FH in
the Lancaster County area by analyzing data gathered from largescale occupational screening of regional employers. Based on the
previous work of Shen (2010) and Andersen (2015), as well as the
longitudinal clinical experience of the LG Health Preventive
Cardiology and Apheresis Clinic, the incidence of severe
hyperlipidemia of potential familial origin was suspected to be
elevated compared to the general population.4,5 Investigation into
the potential population-wide genetic foundations of severe
hyperlipidemia in Lancaster County, as well as their relationship to
the familial defective apolipoprotein B-100 (FDB) founder effect
among the Amish, is ongoing.
Methods
Results
A recent American Heart Association consensus statement proposed an LDLC ≥ 190 mg/dL with a positive family history of hypercholesterolemia as
diagnostic of FH; furthermore, recent genotyping of 98,098 participants in the
Copenhagen Heart Study concluded that an even lower cutoff of 170 mg/dL
was best for identifying FH-causing mutations.6,7 Thus, 190 mg/dL presents
an opportune cutoff for assessment of population risk. Occupational lipid
screening data, including total cholesterol, HDL-C, LDL-C, and non-HDL-C,
from six regional businesses were compiled and queried for LDL-C results
equal to or greater than 190 mg/dL. In total, lipid panel data from 6,375
employees from organizations of varying size were analyzed
Table 1. Occupational lipid screening data from six organizations
Organization
LDL-C ≥ 190 (n)
Participants (n)
Ratio
A
17
953
1/56
B
2
47
1/24
C
5
592
1/118
D
5
156
1/31
E
1
169
1/169
F
63
4458
1/71
Total
93
6375
1/69
93 of 6,375 employees displayed LDL-C ≥ 190 mg/dL, a
rate of 1.45%. In the studied employee population, one in
sixty nine (1/69) subjects displayed uncontrolled severe
hyperlipidemia currently presented as a cutoff for
consideration of familial hypercholesterolemia. Aggregated
occupational screening data across organizations is
shown below.
Discussion
Although the presented occupational data does not
represent a random, representative sample of the Lancaster
County population and may be affected by inclusion biases,
the high rate of severe, untreated hyperlipidemia detected
among 6,375 employees (1.45%) indicates a need for
further exploration of dyslipidemia as a public health
concern in the Lancaster region. Occupational lipid
screening presents an opportunity for collaboration between
public health officials, researchers, and local employers to
screen and analyze large cohorts, providing easily
accessible estimates of population risk. While the genetic
foundations of the phenotypic severe hyperlipidemia remain
unknown, the phenotype indicates a high rate of untreated
hyperlipidemia among working adults, potentially placing a
significant cost burden on regional health providers. While
an LDL-C of190 mg/dL does not represent a highly specific
lipid “cutpoint” in the general population, this effect may be
partially offset by partially treated individuals not detected.
References
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Hopkins PN, Toth PP, et al. Familial hypercholesterolemia: screening, diagnosis and management of pediatric and adult patients: clinical guidance from the National Lipid Association Expert Panel on Familial Hypercholesterolemia. J Clin Lipidol. 2011;5(3 Suppl):S1-8. 3. Sinderman, AD,
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