Current management for a patient at risk for coronary heart disease mandates risk-appropriate lipid intervention. The majority of patients with significant lipid disorders may be successfully managed with a combination of therapeutic lifestyle change (diet, exercise and weight management) and drug therapy.
Patients with genetic lipid disorders or with intolerable side effects from lipid-altering drug therapy may provide a therapeutic challenge. However, for those individuals with markedly elevated LDL cholesterol levels, LDL apheresis may be the only therapeutic option available. LDL apheresis is the process of filtration of venous blood to remove up to 80 percent of LDL cholesterol and many associated inflammatory mediators to treat the lipid disorder and to reduce the likelihood of coronary heart disease progression. This procedure is offered at University Hospitals Harrington Heart & Vascular Institute.
LDL apheresis has three specific indications:
- Patients with homozygous familial hypercholesterolemia; or
- Patients with heterozygous familial hypercholesterolemia and an LDL-C ≥300 mg/dl, despite six months of maximal lifestyle change therapy and failure to respond adequately to two different categories of lipid altering drugs; or
- Patients with coronary heart disease (myocardial infarction, coronary artery bypass surgery, percutaneous coronary intervention, or progressive angina pectoris documented by exercise or pharmacologic stress testing) and an LDL-C ≥ 200 mg/dl, despite six months of maximal lifestyle change therapy and failure to respond adequately to two different categories of lipid altering drugs.
LDL apheresis requires two intravenous lines, one for the removal of venous blood and the other for the return of filtered blood to the patient. The procedure lasts two to three hours.
Two types of systems are currently approved for LDL apheresis in the United States. The most widely employed system, the Liposorber, employs dextran sulfate LDL adsorption onto dextran sulfate containing cellulose beads; the other system, heparin-induced extracorporeal LDL precipitation (HELP), works by removing positively charged apolipoprotein B particles via precipitation with negatively charged heparin. Both systems effectively lower LDL cholesterol and remove inflammatory mediators of the atherosclerotic process.
Patients usually undergo a treatment every two weeks. About 75 percent of patients are able to be treated long-term with peripheral venous access. The remaining 25 percent require other forms of vascular access, most often fistulas.
Studies done in heterozygous familial hypercholesterolemia patients have shown a 72 percent reduction in coronary event rates (absolute reduction of 26 percent) in LDL apheresis patients as compared to those treated with drug therapy alone (p=0.0088).
Patients who meet the specific indications noted above are candidates for the procedure, which is covered by most private health insurers, Medicare and other government payers. Occasionally patients who are close to these criteria, but who do not meet the absolute indications, may be covered for LDL apheresis, but are evaluated by insurance carriers on a case-by-case basis.
How to Refer
Patients should be referred for evaluation for the LDL apheresis program by calling University Hospitals Harrington Heart & Vascular Institute at 216-844-3800.