Atherotech’s VAP+ is a simple non-fasting blood test that directly measures your cardiovascular risk and disease progression that breaks down lipid abnormalities into three categories: triglycerides, cholesterol and hereditary components. The basic lipid does NOT fully assess cardiovascular risk/disease. Often, misclassifying the high risk patients approximately 60% of the time; and inaccurately reports a falsely low LDL, the main target of therapy. Why would anyone with family history of cardiovascular disease NOT want this complete assessment at NO additional cost???? Call 202-527-1953 to find out where to get your VAP+ test done, today! *Additional markers included in the VAP+ report are LDL-P, Lp(a), remnants (IDL, VLDL3), ApoB and Apo A1.

1. VAP+ Lipid Profiling
Comprehensive Lipid Profiling to Personalize
Treatment and Improve Outcomes

2. Presentation Overview
Cardiometabolic
Disease: Current
Challenges and
Methodology
Limitations
Advancements
in
Cardiovascular
Risk
Assessment: The
VAP+
Lipid Panel
Your Partner for
Cardiometabolic
Disease
Management:
Personalized
Treatment and
Patient Education
VAP+ Lipid Panel:
Clinical Evidence
Continues
to Substantiate
VAP Technology
2

3. Cardiometabolic Disease
Current Challenges
and Methodology Limitations

4. CVD Is an Epidemic
Cardiovascular
Disease
Metabolic
Disease
• 1 in 3 US adults has 1 or more types of CVD1
• Heart disease accounts for 25% of all US mortalities2
• 811,940 yearly deaths from CVD
• CVD kills more women each year than the next 3 causes
of death combined3
• Diabetes affects 25.8 million people of the US population
• Diabetes markedly increases the risk of MI, stroke, amputation, and death
as a result of metabolic abnormalities4
• At least 65% of people with diabetes die from some form of heart disease
or stroke5
• NCEP ATP III established diabetes as a CVD risk equivalent in mandating
aggressive antiatherosclerotic therapy4,6
NCEP ATP III=National Cholesterol Education Program Adult Treatment Panel III.
1.
2.
3.
Roger VL, et al. Circulation. 2011;123(4):e18-e209.
Gutstein DE, et al. Clin Pharmacol Ther. 2012;91(1).
WomenHeart. Available at: http://c.ymcdn.com/sites/www.womenheart.org/resource/
resmgr/docs/women,_heart_disease,_and_di.pdf. Accessed September 4, 2013.
4.
5.
6.
Beckman JA, et al. JAMA. 2002;287(19).
NDEP. Available at: http://ndep.nih.gov/media/CVD_FactSheet.pdf.
Accessed August 13, 2013.
NCEP Adult Treatment Panel III. Circulation. 2002;106(25):3143-3421.
4

5. Defining Cardiometabolic Risk
Assessing cardiometabolic risk is necessary
to establish personalized treatment strategies to improve outcomes
Metabolic Syndrome
Traditional
Risk Factors
• Abdominal obesity
• Hypertriglyceridemia
•  HDL-C
•  Blood pressure
•  Glycemia or diabetes
• Age
• Family history
• Gender
•  Blood pressure
•  Cholesterol
• Diabetes
• Smoking
Nontraditional
Risk Factors
• Genetics
• Prothrombotic state
• Inflammatory profile
Cardiometabolic Risk
Evidence-based guidelines recommend a personalized treatment strategy through
cardiometabolic risk stratification and comprehensive lipid profiling.
Adapted from: Tremblay M, et al. J Can Dent Assoc. 2011;77:b125.
5

6. Accurate CVD Identification and Management
Remain a Challenge
•
•
•
•
CVD remains challenging to diagnose, treat, and prevent1
Many patients do not achieve therapeutic goals for LDL-C, HDL-C, and TGs2
Statin adherence is <50% after 4 years in patients 65 and older3
Basic lipid panel utilization of the Friedewald formula significantly
underestimates LDL-C and may lead to undertreatment of at-risk patients4
50% of men and
64% of women
who die suddenly
from heart disease
have no previous
warning signs5
50% of people
who have a CVD
event have
normal cholesterol6
Estimated values
from basic lipid
panels miss 60%
of those at risk
for CVD4
TG=triglycerides.
1.
2.
3.
Roger VL, et al. Circulation. 2011;123(4):e18-e209.
Stacy TA, Egger A. J Manag Care Pharm. 2006;12(9).
Bemmer JS, et al. JAMA 2002;288.
4.
5.
6.
Martin SS, et al. J Am Coll Cardiol. 2013.
Gutstein DE, et al. Clin Pharmacol Ther. 2012;91(1).
Sachdeva A, et al. Am Heart J. 2009;157(1):111-117 e112.
6

7. The Basic Lipid Panel Fails to Identify 60%
of At-Risk Patients
Basic Lipid Panel
Does Not Identify 60%
of Those at Risk for CVD
• BLP developed by Friedewald in 19721
• Generally agreed to be inaccurate in non-fasting
state and when
-70
• Problematic patients for BLP/Friedewald include 5
◦
◦
◦
◦
◦
◦
Frederickson class I, III, or V hyperlipoproteinemia1
Nonselective beta blocker users
Diabetes, insulin resistance, or metabolic syndrome
Liver disease
Nephrotic syndrome or chronic renal insufficiency
Hormone replacement6
% Error in LDL-C
-60
◦ Fasting 12 hours
◦ TG 150 mg/dL2-3
◦ LDL-C 100 mg/dL4
-50
-40
-30
-20
-10
0
<100 mg/dL
100-149
mg/dL
150-199
mg/dL
200-399
mg/dL
Triglycerides
1.
2.
3.
Friedewald WT, et al. Clin Chem. 1972;18(6).
Lindsey CC, et al. Pharmacotherapy. 2004;24(2).
Martin SS, et al. J Am Coll Cardiol. 2013.
4.
5.
6.
Scharnagl H, et al. Clin Chem Lab Med. 2001;39(5):426-431.
NCEP ATP III. Circulation. 2002;106(25).
Legault C, et al. J Clin Epidemiol. 1999;52(12).
7

8. Magnitude of Underestimation
in the basic lipid panel/Friedewald LDL-C
In the Johns Hopkins VLDL study of 1.3 million adults, misclassification of VLDL was significant in
the following classes of patients:
• Patients with abnormal TG levels: 25-60% should be reclassified into a higher risk category
• Patients with normal TG levels: 10-20% should be reclassified into a higher risk category
60
Discordance in BLP/Friedewald and Direct LDL-C by TG
59.4%
Strata
51.9%
50
LDL-C 70-99 mg/dL
39.1%
Error (%)
40
39.1 %
n=13,265
n=10,838
LDL-C <70 mg/dL
30
20.3%
20
10.4%
10
0
n=8042
n=2678
<100 mg/dL
n=11,456
n=10,544
100-149 mg/dL
150-199 mg/dL
n=24,988
n=19,677
200-399 mg/dL
Triglycerides
The basic lipid panel misclassifies patient risk
Martin SS, et al. J Am Coll Cardiol. 2013.
8

9. Advancements in
Cardiovascular Risk Assessment:
The VAP+ Lipid Panel

10. Interactive Question
What are the emerging risk factors outlined in the
national guidelines?
1. Lp(a)
2. Small LDL pattern
3. ApoB and remnant lipoproteins
4. All of the above
10

11. Evidence-Based Guidelines Recommend
Comprehensive Risk Factor Assessment
• LDL-C accounts for 30% of the risk of premature CVD, while the remaining 70%
represents residual risk factors1
• Residual risk can be attributed to LDL-C subclasses, remnant lipoproteins, and other
HDL-C components2-4
• Cardiometabolic risk stratification and personalized approach to management
are recommended2-4
National Guidelines2-5
• Direct LDL-C measurement
• Secondary targets of therapy
◦ Non–HDL-C and metabolic syndrome
• Emerging risk factors
◦ Lp(a), HDL-C subclasses, small LDL pattern, ApoB, and remnant lipoproteins
VAP+ is the first comprehensive lipid profile
to comply with NCEP ATP III, ADA, and AACE guidelines
1.
2.
3.
Kreisberg RA, Oberman A. J Clin Endocrinol Metab. 2002;87(2).
NCEP ATP III. Circulation. 2002;106(25).
Brunzell JD, et al. Diabetes Care. 2008;31(4).
4.
5.
Grundy SM, et al. Circulation. 2004;110(2).
Jellinger PS, et al. Endocr Pract. 2012;18(suppl 1):
11

12. The Comprehensive VAP+ Lipid Panel
Is Essential to Cardiometabolic Risk Stratification
• The VAP+ Lipid Panel provides the most accurate risk
assessment, enabling personalized treatment based on 3 key
indicators not measured by the basic lipid panel
Heredity
Identifies Lp(a),
a hereditary marker
of risk
Cholesterol
Directly measures
LDL-C, LDL-P,
and HDL-C
Triglycerides
Identifies TG-rich disorders, including
non–HDL-C, even in patients with
seemingly normal TG levels
12

13. HEREDITY
TRIGLYCERIDES
CHOLESTEROL
VAP+ Lipid Panel Uncovers Residual
Cardiometabolic Risk and Drives Personalized Therapy
CVD RISK ASSESSMENT
The CVD Risk Assessment
LDL
TGs
LOWER Lp(a)
gives a snapshot of the
• Consider LDL-C
Statins acid
patient’s cardiovascular
Nicotinic
risk. • goals below
Caution 3
• Resins markers on
Omega
the side indicate risk level;
• current guidelines
Cholesterol
fatty acids
absorption
• Consider
additional information in
• Fibric acid
inhibitors
nicotinic acid
the sections below further
• Low-sugar diet
• Consider risk.
Diet low in
clarifies patient baby
• aspirin if not
Exercise fat
saturated
and fried food
contraindicated
• Exercise
The VAP+ Lipid Panel offers detailed results that
enable personalized treatment to directly target
underlying problems
13

14. Global Risk Assessment Mandates
VAP+ Technology
• The VAP+ Lipid Panel uses direct measurement by ultracentrifugation;
therefore, is accurate in non-fasting or fasting patients
• All lipoproteins are physically separated and reacted with an enzymatic
cholesterol reagent, measuring all lipoproteins directly, which increases
the accuracy of the method1
• VAP+ simultaneously measures cholesterol concentrations of ALL
5 lipoprotein classes
The VAP+ Lipid Panel now includes the proprietary
Vertical Lipoprotein Particle (VLP+) technology, which allows
for accurate particle measurement
1.
Kulkarni KR. Clin Lab Med. 2006;26(4).
14

15. Lipoprotein Metabolism
Treatment Options:
Omega 3 Fatty Acids
Statins, Bile Acid
Sequestrants, Ezetimibe
Fibrate, Niacin, Omega 3 Fatty Acids
Large, Buoyant
Pattern A
VLDL
Healthy
Food
IDL
LDL
Chylomicrons
Small
Intestines
intestines
Liver
Lp(a)
Atherogenic
Small, Dense
Pattern B
Unhealthy
Food
LDL
Chylomicrons
VLDL1+2
VLDL3
IDL
(Increased LDL-P
Concentration)
15

16. VAP+ Lipid Panel:
The Importance of LDL Pattern
• LDL patterns carry different CHD risks
Pattern A: Characterized by
larger, more buoyant
lipoprotein particles (LDL1,2)1
Pattern B: Characterized by
smaller, denser lipoprotein
particles (LDL3,4)1
• Although total LDL-C concentration can be similar in pattern A or B patients, pattern B
patients present with a higher concentration of LDL-P2
• Pattern B particles are more easily taken up by arterial tissue than pattern A particles 2
• Due to altered properties of the surface lipid layer, pattern B particles are more
susceptible to oxidation2
1.
2.
Austin MA, et al. Circulation. 1990;82(2).
Rizzo M, Berneis K. QJM. 2006;99(1).
16

17. Significance of LDL Particle Concentration
• This animation illustrates that 2 individuals with the same total
LDL-C can have different LDL-P concentrations, leading to different
CHD risk levels
Pattern A
B
Individuals with high LDL-P
Individuals with low
have predominantly small and dense
usually have large, buoyant, pattern A
pattern B LDL-C particles
LDL-C particles
*Note both individuals have same amount of TC.
17

18. LDL Particle Concentration Indicates Risk
• In practical application, 2 patients have identical LDL-C—which
patient is at greater risk?
Lower Risk
Higher Risk
B
20 mg/dL
A
100 mg/dL
Large LDL-C
(Pattern A)
LDL-C=100 mg/dL
LDL-P=1100 nmol/L
B
20 mg/dL
B
20 mg/dL
B
20 mg/dL
B
20 mg/dL
Small LDL-C
(Pattern B)
LDL-C=100 mg/dL
LDL-P=1800 nmol/L
Assessment of true LDL-P using the VAP+ Lipid Panel allows for isolation of the actual cause
of increased total LDL-P number to help personalize treatment and improve outcomes
18

19. Appropriate Patients to Consider for VAP+ Testing
Moderate- and
higher-risk
individuals and
those at risk
for CVD
Any patient with
NCEP ATP III
risk factors
(5 established):
• Family history of
premature CHD
• Age (men 45
years; women
55 years)
• Cigarette smoking
• Hypertension
• Low HDL-C
( 40 mg/dL)
Established
atherosclerotic
vascular disease
Diabetes mellitus
and/or metabolic
syndrome
Framingham Risk
Score (FRS)
over 5% or
Reynolds
Risk Score
An elevated
inflammatory
biomarker
19

20. VAP+ Lipid Panel
Clinical Evidence Continues
to Substantiate VAP Technology

21. Interactive Question
Which of the following is true about residual risk after
statin therapy?
1. Residual risk for CVD remains despite a significant reduction
in CV events and mortality with statin therapy.
2. Substantial residual risk persists even after patients are treated
with intensive statin therapy to reduce LDL-C.
3. High TGs and low levels of HDL-C appear to be major contributors
to residual risk, even at optimal LDL-C levels.
4. All of the above are correct.
21

22. VAP+ Lipid Panel Evidence Summary
HDL-C subclass is
an independent risk factor
The basic lipid panel
misclassifies CVD risk
• The BLP/Friedewald formula consistently
underestimates LDL-C, resulting in
undertreatment of high-risk patients1
• Framingham Heart Study: Increased
HDL3-C revealed a 40% lower risk for
CHD and 36% lower risk for hard CHD4
(primary prevention)
• Intermountain Heart Collaborative Study:
A large percentage of patients with heart
disease remain at high residual risk despite
having achieved basic lipid panel target
LDL-C treatment goals2
(secondary prevention)
• TRIUMPH Study: Low HDL3-C revealed
a 50% higher mortality risk5
(secondary prevention)
• Jackson Heart Study: Increased HDL3-C
revealed a 68% lower risk for hard CHD
and a 35% lower risk for CHD6
(primary prevention)
• Low HDL2-C reveals CV risk in 6 times as
many patients as the basic lipid panel3
(primary prevention)
1.
2.
3.
Martin SS, et al. J Am Coll Cardiol. 2013.
May HT, et al. Presented at: ACC 59th Annual Scientific Sessions; 2010.
Sailam V, et al. Clin Cardiol. 2008;31(11):542-545.
4.
5.
6.
Toth P. et al Impact of HDLC and its subfractions. 2012.
Martin SS. Presented at: AHA Scientific Sessions; 2012.
Joshi P, et al. Presented at: AHA Scientific Sessions; 2012.
22

23. VAP+ Lipid Panel Evidence Summary
Remnant lipoproteins predict heart attack risk
• Jackson Heart Study: Remnant lipoproteins are 28% more likely to reveal a significant, independent
risk factor for heart attack1 (primary prevention)
• Framingham Heart Study: Remnant lipoproteins were an independent risk factor for incident CHD
events2 (primary prevention)
• Framingham Heart Study: Pattern B revealed double the risk for hard CHD and a 40% increased risk
for CHD3 (primary prevention)
• Atherogenic lipoprotein phenotype (LDL-C pattern B) reveals double the risk for hard CHD and 40%
increased risk for CHD and is strongly associated with CIMT progression4
Elevated Lp(a) plays a significant role in atherogenesis and is closely
associated with HDL-C, VLDL-C, and TGs
• Studies by Konerman’s group utilizing the VAP+ cholesterol test have shown that Lp(a) is strongly
associated with markers of HDL-C, VLDL-C, and TGs, and highlight Lp(a)’s role in atherogenesis5
(primary and secondary prevention)
CIMT=carotid intima media thickness.
1.
2.
Khokar A, et al. J Am Coll Cardiol. 2013;61(10S).
Toth PP, et al. Presented at: ACC Scientific Sessions; 2013. Impact of Lipoprotein Remnants
on 12 Year Risk for CHD in the Framingham Offspring Population.
3.
4.
5.
Toth PP. Presented at: AHA Scientific Sessions; 2012. Impact of LDL patterns on risk for CHD
in the Framingham Offspring Population.
Maki KC, et al. Vasc Health Risk Manag. 2012;8.
Konerman M, et al. J Clin Lipidol. 2012;6(1).
23

24. VAP+ Lipid Panel Improves Outcomes
and Reduces Cost for Managed Care
• Use of the VAP+ Lipid Panel permitted WellMed Medical Group to
detect more cases of dyslipidemia than the basic lipid panel, enabling
more appropriate and effective therapy to be prescribed
and, ultimately, leading to better outcomes1,2
◦ Repeated VAP testing and therapy adjustments led to lower LDL-C, higher
HDL3-C, reduced inpatient (IP) stays, and fewer emergency department (ED) visits
Utilization and Cost Comparisons
IMPROVED
PATIENT
OUTCOMES
REDUCED COSTS
TO MANAGED
CARE BY
35%
VAP
Test
Group
Control
Test
Results
P-Value
Mean total cost
year 1
$4307.70
$5146.02
-1.34*
0.1157
Mean total cost
year 2
$4852.62
$7413.18
-2.24*
0.0255
Mean ED cost
both years
$22.24
$33.15
-1.92*
0.0561
Mean IP cost
both years
$732.80
$876.20
-1.80*
0.0722
Cost
*t-test.
1.
Atherotech Inc. Available at: http://www.atherotech.com/information/viewinformation.asp?informationid=179. Accessed August 13, 2012.
2.
McAna JF, et al. Popul Health Manag. 2012;15(1).
24

25. Improving Health Outcomes
Through Cardiometabolic
Testing and Patient Education

26. Our Healthy Heart Patient Education Program
Our Healthy Heart is a unique service offered by
Atherotech at no additional charge with a
VAP+ Lipid Panel.
The service provides patients with personalized
lifestyle modification education, compliance
strategies, and coaching from licensed health
coaches to promote heart health through the
continuum of care.
Our licensed health coaches can design a
personalized program based on physician
recommendations, patient needs, and
VAP+ results.
Call 1-866-VAP-TEST or 1-866-827-8378
toll-free to enroll your patient.
26

27. Atherotech Offers Customizable Disease
State Panels
These disease state panels are provided as
examples only. Physicians should only order
tests that are medically necessary and
reasonable for the diagnosis or treatment of a
patient for which reimbursement is claimed. All
tests included in Atherotech panels or physiciancreated panels may be ordered individually.
Through proprietary technologies, including
the VAP+ Lipid Panel, Atherotech supports a
full offering of disease state panels that can
be customized by the clinician.
CARDIOMETABOLIC AND GENETIC TESTS FROM ATHEROTECH
CVD Risk Panel
•
•
•
•
•
•
VAP+ Lipid Panel
CMP
Lp-PLA2
Hs-CRP
Homocysteine
Cystatin C
CVD Treatment
Panel
•
•
•
•
•
•
•
•
VAP+ Lipid Panel
CMP
Lp-PLA2
Hs-CRP
Homocysteine
Cystatin C
TSH
Uric acid
Diabetes/Metabolic
Syndrome Panel
•
•
•
•
•
•
•
•
VAP+ Lipid Panel
CMP
A1C
GlycoMark
GGT
Uric acid
Cystatin C
Insulin
Heart Failure
Panel
•
•
•
•
•
VAP+ Lipid Panel
BMP
NTproBNP
Galectin 3
Cystatin C
Myalgia Panel
•
•
•
•
•
VAP+ Lipid Panel
B12
TSH
Vitamin D
Uric acid
27

28. In Conclusion
Comprehensive care is essential to effectively manage cardiometabolic risk and
improve outcomes
Basic lipid panels have led to misclassification of as many as 60% of
patients, potentially resulting in ineffective treatment for patients most at risk
Evidence-based guidelines recommend cardiometabolic risk stratification via
comprehensive cholesterol profiling so a personalized treatment strategy can
be implemented
The VAP+ Lipid Panel uncovers residual cardiometabolic risk, which provides
actionable information to improve patient outcomes
Atherotech provides over 100 routine and cardiometabolic specialty tests and
customizable disease state panels to offer clinicians a single source laboratory
Atherotech goes beyond diagnostics to offer personalized provider and patient
education for disease management
28

29. “If something doesn’t
make sense perhaps you
should look further”.