Counterpoint: Flexibilization of Fasting for Laboratory Determination of the Lipid Profile in Brazil: Science or Convenience?

Maria Cristina de Oliveira Izar About the author

Keywords
Dyslipidemias; Cholesterol; Lipids; Triglycerides; Cholesterol, HDL; Cholesterol, LDL; Fasting

National and international guidelines for the management of dyslipidemias classically recommend measuring lipid profiles after fasting for at least 8 h.11 Bailie EE. Report from the Laboratory Standardization PaneI of the National Cholesterol Education Program: recommendations for improving cholesterol measurement. 1993. Lab Medicine. 1990;21(7):429-35. (NIH Publication Nº 93-2964).

2 Catapano AL, Reiner Z, De Backer G, Graham I, Taskinen MR, Wiklund O, et al; European Society of Cardiology (ESC); European Atherosclerosis Society (EAS). ESC/EAS Guidelines for the management of dyslipidaemias The Task Force for the management of dyslipidaemias of the European Society of Cardiology (ESC) and the European Atherosclerosis Society (EAS). Atherosclerosis. 2011;217(1):3-46.
-33 Xavier HT, Izar MC, Faria Neto JR, Assad MH, Rocha VZ, Sposito AC, et al. [V Brazilian guidelines on dyslipidemias and prevention of atherosclerosis]. Arq Bras Cardiol. 2013;101(4 Suppl 1):1-20. Lipid targets for assessing cardiovascular risk traditionally rely on plasma total-cholesterol and low-density lipoprotein-cholesterol (LDL-c) levels, with the latter being calculated by the Friedewald equation.44 Friedewald WT, Lavy RI, Fredrickson DS. Estimation of the concentration of low-density lipoprotein cholesterol in plasma, without use of the preparative ultracentrifuge. Clin Chem. 1972;18(6):499-502.

Some imprecision due to low or high triglycerides in calculating LDL-cholesterol may affect cardiovascular risk assessment, the definition of a therapeutic target, and the need to intensify the treatment.55 Sociedade Brasileira de Patologia Clínica/Medicina Laboratorial. SBPC. Brazilian Society of Clinical Pathology. Laboratory determination of the lipid profile. [Cited in 2016 Dec 10]. Available from: http://www.sbpc.org.br/upload/conteudo/consenso_jejum_dez2016_final.pdf
http://www.sbpc.org.br/upload/conteudo/c...
,66 Faludi AA, Izar MC, Saraiva JF, Chacra AP, Bianco HT, Afiune Neto A, et al. Atualização da Diretriz Brasileira de dislipidemias e prevenção da aterosclerose - 2017. Arq Bras Cardiol. 2017;109(2 Supl.1):1-76. Accurate results require triglyceride levels below 400 mg/dL, but above 100 mg/dL the calculated LDL-c starts to be underestimated, when compared to ultracentrifugation measurements. Another limitation to the use of the formula is that samples must not contain beta-VLDL, as in the case of type III hyperlipoproteinemia. When one of these conditions are not satisfied, the equation cannot be used due to imprecision.55 Sociedade Brasileira de Patologia Clínica/Medicina Laboratorial. SBPC. Brazilian Society of Clinical Pathology. Laboratory determination of the lipid profile. [Cited in 2016 Dec 10]. Available from: http://www.sbpc.org.br/upload/conteudo/consenso_jejum_dez2016_final.pdf
http://www.sbpc.org.br/upload/conteudo/c...

6 Faludi AA, Izar MC, Saraiva JF, Chacra AP, Bianco HT, Afiune Neto A, et al. Atualização da Diretriz Brasileira de dislipidemias e prevenção da aterosclerose - 2017. Arq Bras Cardiol. 2017;109(2 Supl.1):1-76.
-77 Nordestgaard BG, Langsted A, Mora S, Kolovou G, Baum H, Bruckert E, et al; European Atherosclerosis Society (EAS) and the European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) joint consensus initiative. Fasting is not routinely required for determination of a lipid profile: clinical and laboratory implications including flagging at desirable concentration cut-points-a joint consensus statement from the European Atherosclerosis Society and European Federation of Clinical Chemistry and Laboratory Medicine. Eur Heart J. 2016;37(25):1944-58.

Other lipid parameters, such as apolipoprotein-B and non-high-density lipoprotein-cholesterol (non-HDL-C) reflect the pool of atherogenic lipoproteins and have emerged as good markers to improve cardiovascular risk assessment, and also to guide lipid-lowering therapy.22 Catapano AL, Reiner Z, De Backer G, Graham I, Taskinen MR, Wiklund O, et al; European Society of Cardiology (ESC); European Atherosclerosis Society (EAS). ESC/EAS Guidelines for the management of dyslipidaemias The Task Force for the management of dyslipidaemias of the European Society of Cardiology (ESC) and the European Atherosclerosis Society (EAS). Atherosclerosis. 2011;217(1):3-46.,33 Xavier HT, Izar MC, Faria Neto JR, Assad MH, Rocha VZ, Sposito AC, et al. [V Brazilian guidelines on dyslipidemias and prevention of atherosclerosis]. Arq Bras Cardiol. 2013;101(4 Suppl 1):1-20.,88 Chapman MJ, Ginsberg HN, Amarenco P, Andreotti F, Boren J, Catapano AL, et al; European Atherosclerosis Society Consensus Panel. Triglyceride-rich lipoproteins and high-density lipoprotein cholesterol in patients at high risk of cardiovascular disease: evidence and guidance for management. Eur Heart J. 2011;32(11):1345-61.,99 Miller M, Stone NJ, Ballantyne C, Bittner V, Criqui MH, Ginsberg HN, et al; American Heart Association Clinical Lipidology, Thrombosis, and Prevention Committee of the Council on Nutrition, Physical Activity, and Metabolism; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular Nursing; Council on the Kidney in Cardiovascular Disease. Triglycerides and cardiovascular disease: a scientific statement from the American Heart Association. Circulation. 2011;123(20):2292-333. These variables can be used in both the fasting and non-fasting states, and non-fasting lipoproteins are regarded as better atherosclerotic risk predictors, when compared with fasting ones, for they reflect remnant, atherogenic lipoproteins, with higher correlation with cardiovascular risk.22 Catapano AL, Reiner Z, De Backer G, Graham I, Taskinen MR, Wiklund O, et al; European Society of Cardiology (ESC); European Atherosclerosis Society (EAS). ESC/EAS Guidelines for the management of dyslipidaemias The Task Force for the management of dyslipidaemias of the European Society of Cardiology (ESC) and the European Atherosclerosis Society (EAS). Atherosclerosis. 2011;217(1):3-46.,33 Xavier HT, Izar MC, Faria Neto JR, Assad MH, Rocha VZ, Sposito AC, et al. [V Brazilian guidelines on dyslipidemias and prevention of atherosclerosis]. Arq Bras Cardiol. 2013;101(4 Suppl 1):1-20.,88 Chapman MJ, Ginsberg HN, Amarenco P, Andreotti F, Boren J, Catapano AL, et al; European Atherosclerosis Society Consensus Panel. Triglyceride-rich lipoproteins and high-density lipoprotein cholesterol in patients at high risk of cardiovascular disease: evidence and guidance for management. Eur Heart J. 2011;32(11):1345-61.,99 Miller M, Stone NJ, Ballantyne C, Bittner V, Criqui MH, Ginsberg HN, et al; American Heart Association Clinical Lipidology, Thrombosis, and Prevention Committee of the Council on Nutrition, Physical Activity, and Metabolism; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular Nursing; Council on the Kidney in Cardiovascular Disease. Triglycerides and cardiovascular disease: a scientific statement from the American Heart Association. Circulation. 2011;123(20):2292-333.

To avoid the interference of triglycerides, direct measurements of LDL-cholesterol have been developed.1010 Tanno K, Okamura T, Ohsawa M, Onoda T, Itai K, Sakata K, et al. Comparison of low-density lipoprotein cholesterol con- centrations measured by a direct homogeneous assay and by the Friedewald for- mula in a large community population. Clin Chim Acta. 2010;411(21-22):1774-80.,1111 Mora S, Rifai N, Buring JE, Ridker PM. Comparison of LDL cholesterol concentra- tions by Friedewald calculation and direct measurement in relation to cardiovascular events in 27,331 women. Clin Chem. 2009;55(5):888-94. but these techniques lack proper standardization, and were tested in few clinical trials that use LDL-c as target.1212 Mihaylova B, Emberson J, Blackwell L, Keech A, Simes J, Barnes EH, et al; Cholesterol Treatment Trialists' (CTT) Collaborators. The effect of lowering LDL cholesterol with statin therapy in people at low risk of vascular disease: meta-analysis of individual data from 27 randomised trials. Lancet. 2012;380(9841):581-90.,1313 Boekholdt SM, Arsenault BJ, Mora S, Pedersen TR, LaRosa JC, Nestel PJ, et al. Association of LDL cholesterol, non-HDL cholesterol, and apolipoprotein B levels with risk of cardiovascular events among patients treated with statins. JAMA. 2012;307(12):1302-9. Erratum in: JAMA. 2012;307(18):1915. JAMA. 2012;307(16):1694.

Since then, many papers, as result of important and broad studies, were carried out comparing fasting and non-fasting lipid parameters, mainly total cholesterol, HDL-c, LDL-c and triglycerides, concluding that non-fasting lipids do not clinically differ from fasting ones, except for triglycerides, that require different reference values for non-fasting state.1414 Langsted A, Freiberg JJ, Nordestgaard BG. Fasting and nonfasting lipid levels: influence of normal food intake on lipids, lipoproteins, apolipoproteins, and cardiovascular risk prediction. Circulation. 2008;118(20):2047-56.,1515 Langsted A, Kamstrup PR, Nordestgaard BG. Lipoprotein(a): fasting and nonfasting levels, inflammation, and cardiovascular risk. Atherosclerosis. 2014;234(1):95-101.

Here we present a second opinion for what has been stated in the article: “Flexibilization of fasting for laboratory determination of the lipid profile in Brazil: science or convenience?”

Our second opinion uses steps for building a scientific statement. The first step is to find an issue of interest to be debated. The second step requires full understanding of what is currently known about what is being explained. This basically deals with scientific publications, citations seeking other scientific papers, and books on the topic. Although it is possible to defer to the scientific consensus, you cannot really have a personal scientific viewpoint on anything without understanding what current research says about it.

Keep in mind that all scientific papers should be found in peer-reviewed well-reputed journals. It is best to approach scientific literature with no prior judgements; however, it can be a difficult task. After reviewing all relevant papers to the matter, it is possible to develop a scientific view and an opinion. If the scientific material collected reaches the same conclusion, it is unlikely that you can hold a different viewpoint at this moment. But, if some papers disagree, there is room for debate and to raise a plausible second opinion, if there is good research supporting this view. High-quality, well-designed studies, with a large number of participants, in the opposite direction of what had been stated, do reinforce the validity of a second opinion.

This article will address the interpretation, applications and limitations of a non-fasting lipid profile for daily clinical practice.

First, large observational data, with population-based studies and registries, including 111,048 women, 98,132 men, 12,744 children, and patients with diabetes, in which non-fasting lipid profiles were compared with those obtained under fasting conditions, have demonstrated that the maximal changes in plasma lipids and lipoproteins occurred between 1-6 hrs. after a usual meal. These trials have established that only minor changes occurred in response to habitual food intake in the majority of individuals.1414 Langsted A, Freiberg JJ, Nordestgaard BG. Fasting and nonfasting lipid levels: influence of normal food intake on lipids, lipoproteins, apolipoproteins, and cardiovascular risk prediction. Circulation. 2008;118(20):2047-56.,1616 Mora S, Rifai N, Buring JE, Ridker PM. Fasting compared with nonfasting lipids and apolipoproteins for predicting incident cardiovascular events. Circulation. 2008;118(10):993-1001.

17 Sidhu D, Naugler C. Fasting time and lipid levels in a community-based population: a cross-sectional study. Arch Intern Med. 2012;172(22):1707-10.

18 Steiner MJ, Skinner AC, Perrin EM. Fasting might not be necessary before lipid screening: a nationally representative cross-sectional study. Pediatrics. 2011;128(3):463-70.
-1919 Langsted A, Nordestgaard BG. Nonfasting lipids, lipoproteins, and apolipoproteins in individuals with and without diabetes: 58,434 individuals from the Copenhagen General Population Study. Clin Chem. 2011;57(3):482-9. Total cholesterol, LDL-c, remnant cholesterol, varied 8 mg/dL, whereas HDL-c, apolipoprotein A1, apolipoprotein B, and lipoprotein(a) were not affected by fasting/non-fasting status. These data were derived from the Women’s Health Study, the Copenhagen General Population Study, the National Health and Nutrition Examination Survey, and the Calgary Laboratory Services in Canada.1414 Langsted A, Freiberg JJ, Nordestgaard BG. Fasting and nonfasting lipid levels: influence of normal food intake on lipids, lipoproteins, apolipoproteins, and cardiovascular risk prediction. Circulation. 2008;118(20):2047-56.,1616 Mora S, Rifai N, Buring JE, Ridker PM. Fasting compared with nonfasting lipids and apolipoproteins for predicting incident cardiovascular events. Circulation. 2008;118(10):993-1001.

17 Sidhu D, Naugler C. Fasting time and lipid levels in a community-based population: a cross-sectional study. Arch Intern Med. 2012;172(22):1707-10.

18 Steiner MJ, Skinner AC, Perrin EM. Fasting might not be necessary before lipid screening: a nationally representative cross-sectional study. Pediatrics. 2011;128(3):463-70.
-1919 Langsted A, Nordestgaard BG. Nonfasting lipids, lipoproteins, and apolipoproteins in individuals with and without diabetes: 58,434 individuals from the Copenhagen General Population Study. Clin Chem. 2011;57(3):482-9.

Among all studies, only minor increases in plasma triglycerides and minor decreases in total and LDL cholesterol concentrations were observed, in non-fasting conditions, with no change in HDL cholesterol concentrations. In subjects with diabetes, calculated LDL-c obtained 1-3 hours after a meal decreased 23 mg/dL, and could imply in statin withhold; however, when corrected for albumin, reflecting fluid intake, the difference disappeared, and was attributed to the fluid and not to the diet.2020 Simundic AM, Cornes M, Grankvist K, Lippi G, Nybo M. Standardization of collection requirements for fasting samples: for the Working Group on Preanalytical Phase (WG-PA) of the European Federation of Clinical Chemis- try and Laboratory Medicine (EFLM). Clin Chim Acta. 2014 May 15;432:33-7.

Second, we live most of our time in non-fasting state. Non-fasting and fasting lipid concentrations vary similarly over time and are at least equivalent in the prediction of cardiovascular disease. In fact, data from the Calgary Laboratory Services in Canada demonstrated that in ~200,000 men and women, total cholesterol, HDL and LDL-cholesterol did not vary as a function of the period of fasting after the last meal.1717 Sidhu D, Naugler C. Fasting time and lipid levels in a community-based population: a cross-sectional study. Arch Intern Med. 2012;172(22):1707-10.

Third, reference plasma lipid, lipoprotein, and apolipoprotein concentration values based on desirable concentration cutoff points, do not vary when non-fasting, except for triglycerides, which should be flagged as abnormal in laboratory reports > 175 mg/dL. However, non-fasting triglycerides were better predictors than in the fasting state.77 Nordestgaard BG, Langsted A, Mora S, Kolovou G, Baum H, Bruckert E, et al; European Atherosclerosis Society (EAS) and the European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) joint consensus initiative. Fasting is not routinely required for determination of a lipid profile: clinical and laboratory implications including flagging at desirable concentration cut-points-a joint consensus statement from the European Atherosclerosis Society and European Federation of Clinical Chemistry and Laboratory Medicine. Eur Heart J. 2016;37(25):1944-58.

Fourth, the risk of ischemic heart disease and myocardial infarction in 92,285 individuals from the Copenhagen General Population Study recruited from 2003 through 2014, could be predicted by non-fasting lipids (reported in Nordestgaard et al.77 Nordestgaard BG, Langsted A, Mora S, Kolovou G, Baum H, Bruckert E, et al; European Atherosclerosis Society (EAS) and the European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) joint consensus initiative. Fasting is not routinely required for determination of a lipid profile: clinical and laboratory implications including flagging at desirable concentration cut-points-a joint consensus statement from the European Atherosclerosis Society and European Federation of Clinical Chemistry and Laboratory Medicine. Eur Heart J. 2016;37(25):1944-58.).

Fifth, a novel method to estimate LDL-C using an adjustable factor for the TG:VLDL-C ratio provided a more accurate guideline risk classification than the Friedewald equation.2121 Martin SS, Blaha MJ, Elshazly MB, Toth PP, Kwiterovich PO, Blumenthal RS, et al. Comparison of a novel method vs the Friedewald equation for estimating low-density lipoprotein cholesterol levels from the standard lipid profile. JAMA. 2013;310(19):2061-8. The authors used a large convenience sample of consecutive clinical lipid profiles obtained from 2009 through 2011 (n = 1,350,908), including children, adolescents, and adults in the United States). The sample was randomly assigned to derivation (n = 900,605) or validation (n = 450,303) data sets. Results closely matched those in the National Health and Nutrition Examination Survey (NHANES). This estimation method provided higher-fidelity estimates than the Friedewald equation. The greatest improvement in concordance occurred when classifying LDL-C lower than 70 mg/dL, especially in patients with high triglyceride levels. Indeed, there is a need for external validation, and assessment of its clinical importance. However, this novel method could be implemented in most laboratory reporting systems with virtually no cost.

Finally, what would be the problem to add convenience to science? Postprandial measurements are more practical and provide the patient a greater access to the laboratory, and also can decrease the number of missed working days and medical appointments due to missed tests; blood collection in the postprandial state is safer in several circumstances and help prevent hypoglycemia secondary to the use of insulin in patients with diabetes mellitus, in pregnant women, children, and elderly individuals, reducing complications and increasing adherence to the tests and to medical appointments; flexibilization of fasting for lipid profiling, can bring more comfort to the patient and greater amplitude of schedules in the laboratories, especially in the morning; technological advances in diagnostic methods, can mitigate the interference of sample turbidity when triglycerides are high.2222 Scartezini M, Ferreira CE, Izar MC, Bertoluci M, Vencio S, Campana GA, et al. Positioning about the flexibility of fasting for lipid profiling. Arq Bras Cardiol. 2017;108(3):195-7.

If, fasting is not routinely required for assessing the plasma lipid profile, some recommendations should be made in specific situations: 1) when non-fasting plasma triglyceride concentration exceed 440 mg/dL, consideration should be given to repeating the lipid profile in the fasting state; 2) laboratory reports should flag abnormal values based on desirable concentration cut-off points; 3) life-threatening or extremely high concentrations should trigger an immediate referral to a lipid clinic or to a physician with special interest in lipids.77 Nordestgaard BG, Langsted A, Mora S, Kolovou G, Baum H, Bruckert E, et al; European Atherosclerosis Society (EAS) and the European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) joint consensus initiative. Fasting is not routinely required for determination of a lipid profile: clinical and laboratory implications including flagging at desirable concentration cut-points-a joint consensus statement from the European Atherosclerosis Society and European Federation of Clinical Chemistry and Laboratory Medicine. Eur Heart J. 2016;37(25):1944-58.,2222 Scartezini M, Ferreira CE, Izar MC, Bertoluci M, Vencio S, Campana GA, et al. Positioning about the flexibility of fasting for lipid profiling. Arq Bras Cardiol. 2017;108(3):195-7.

  • Sources of Funding
    There were no external funding sources for this study.
  • Study Association
    This study is not associated with any thesis or dissertation work.

References

  • 1
    Bailie EE. Report from the Laboratory Standardization PaneI of the National Cholesterol Education Program: recommendations for improving cholesterol measurement. 1993. Lab Medicine. 1990;21(7):429-35. (NIH Publication Nº 93-2964).
  • 2
    Catapano AL, Reiner Z, De Backer G, Graham I, Taskinen MR, Wiklund O, et al; European Society of Cardiology (ESC); European Atherosclerosis Society (EAS). ESC/EAS Guidelines for the management of dyslipidaemias The Task Force for the management of dyslipidaemias of the European Society of Cardiology (ESC) and the European Atherosclerosis Society (EAS). Atherosclerosis. 2011;217(1):3-46.
  • 3
    Xavier HT, Izar MC, Faria Neto JR, Assad MH, Rocha VZ, Sposito AC, et al. [V Brazilian guidelines on dyslipidemias and prevention of atherosclerosis]. Arq Bras Cardiol. 2013;101(4 Suppl 1):1-20.
  • 4
    Friedewald WT, Lavy RI, Fredrickson DS. Estimation of the concentration of low-density lipoprotein cholesterol in plasma, without use of the preparative ultracentrifuge. Clin Chem. 1972;18(6):499-502.
  • 5
    Sociedade Brasileira de Patologia Clínica/Medicina Laboratorial. SBPC. Brazilian Society of Clinical Pathology. Laboratory determination of the lipid profile. [Cited in 2016 Dec 10]. Available from: http://www.sbpc.org.br/upload/conteudo/consenso_jejum_dez2016_final.pdf
    » http://www.sbpc.org.br/upload/conteudo/consenso_jejum_dez2016_final.pdf
  • 6
    Faludi AA, Izar MC, Saraiva JF, Chacra AP, Bianco HT, Afiune Neto A, et al. Atualização da Diretriz Brasileira de dislipidemias e prevenção da aterosclerose - 2017. Arq Bras Cardiol. 2017;109(2 Supl.1):1-76.
  • 7
    Nordestgaard BG, Langsted A, Mora S, Kolovou G, Baum H, Bruckert E, et al; European Atherosclerosis Society (EAS) and the European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) joint consensus initiative. Fasting is not routinely required for determination of a lipid profile: clinical and laboratory implications including flagging at desirable concentration cut-points-a joint consensus statement from the European Atherosclerosis Society and European Federation of Clinical Chemistry and Laboratory Medicine. Eur Heart J. 2016;37(25):1944-58.
  • 8
    Chapman MJ, Ginsberg HN, Amarenco P, Andreotti F, Boren J, Catapano AL, et al; European Atherosclerosis Society Consensus Panel. Triglyceride-rich lipoproteins and high-density lipoprotein cholesterol in patients at high risk of cardiovascular disease: evidence and guidance for management. Eur Heart J. 2011;32(11):1345-61.
  • 9
    Miller M, Stone NJ, Ballantyne C, Bittner V, Criqui MH, Ginsberg HN, et al; American Heart Association Clinical Lipidology, Thrombosis, and Prevention Committee of the Council on Nutrition, Physical Activity, and Metabolism; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular Nursing; Council on the Kidney in Cardiovascular Disease. Triglycerides and cardiovascular disease: a scientific statement from the American Heart Association. Circulation. 2011;123(20):2292-333.
  • 10
    Tanno K, Okamura T, Ohsawa M, Onoda T, Itai K, Sakata K, et al. Comparison of low-density lipoprotein cholesterol con- centrations measured by a direct homogeneous assay and by the Friedewald for- mula in a large community population. Clin Chim Acta. 2010;411(21-22):1774-80.
  • 11
    Mora S, Rifai N, Buring JE, Ridker PM. Comparison of LDL cholesterol concentra- tions by Friedewald calculation and direct measurement in relation to cardiovascular events in 27,331 women. Clin Chem. 2009;55(5):888-94.
  • 12
    Mihaylova B, Emberson J, Blackwell L, Keech A, Simes J, Barnes EH, et al; Cholesterol Treatment Trialists' (CTT) Collaborators. The effect of lowering LDL cholesterol with statin therapy in people at low risk of vascular disease: meta-analysis of individual data from 27 randomised trials. Lancet. 2012;380(9841):581-90.
  • 13
    Boekholdt SM, Arsenault BJ, Mora S, Pedersen TR, LaRosa JC, Nestel PJ, et al. Association of LDL cholesterol, non-HDL cholesterol, and apolipoprotein B levels with risk of cardiovascular events among patients treated with statins. JAMA. 2012;307(12):1302-9. Erratum in: JAMA. 2012;307(18):1915. JAMA. 2012;307(16):1694.
  • 14
    Langsted A, Freiberg JJ, Nordestgaard BG. Fasting and nonfasting lipid levels: influence of normal food intake on lipids, lipoproteins, apolipoproteins, and cardiovascular risk prediction. Circulation. 2008;118(20):2047-56.
  • 15
    Langsted A, Kamstrup PR, Nordestgaard BG. Lipoprotein(a): fasting and nonfasting levels, inflammation, and cardiovascular risk. Atherosclerosis. 2014;234(1):95-101.
  • 16
    Mora S, Rifai N, Buring JE, Ridker PM. Fasting compared with nonfasting lipids and apolipoproteins for predicting incident cardiovascular events. Circulation. 2008;118(10):993-1001.
  • 17
    Sidhu D, Naugler C. Fasting time and lipid levels in a community-based population: a cross-sectional study. Arch Intern Med. 2012;172(22):1707-10.
  • 18
    Steiner MJ, Skinner AC, Perrin EM. Fasting might not be necessary before lipid screening: a nationally representative cross-sectional study. Pediatrics. 2011;128(3):463-70.
  • 19
    Langsted A, Nordestgaard BG. Nonfasting lipids, lipoproteins, and apolipoproteins in individuals with and without diabetes: 58,434 individuals from the Copenhagen General Population Study. Clin Chem. 2011;57(3):482-9.
  • 20
    Simundic AM, Cornes M, Grankvist K, Lippi G, Nybo M. Standardization of collection requirements for fasting samples: for the Working Group on Preanalytical Phase (WG-PA) of the European Federation of Clinical Chemis- try and Laboratory Medicine (EFLM). Clin Chim Acta. 2014 May 15;432:33-7.
  • 21
    Martin SS, Blaha MJ, Elshazly MB, Toth PP, Kwiterovich PO, Blumenthal RS, et al. Comparison of a novel method vs the Friedewald equation for estimating low-density lipoprotein cholesterol levels from the standard lipid profile. JAMA. 2013;310(19):2061-8.
  • 22
    Scartezini M, Ferreira CE, Izar MC, Bertoluci M, Vencio S, Campana GA, et al. Positioning about the flexibility of fasting for lipid profiling. Arq Bras Cardiol. 2017;108(3):195-7.

Publication Dates

  • Publication in this collection
    Nov 2018

History

  • Received
    07 Apr 2018
  • Reviewed
    11 Apr 2018
  • Accepted
    11 Apr 2018
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