All the Small Things, an absolute classic Blink-182 banger, is still universally played at High School Dances and Track Meets across the country.  But should we also be blaring this Punk Rock Anthem at all our patient visits as we determine if our patients have All the Small Particles as well?  Does determining particle size even matter?

Small dense LDL particles (sdLDL-P), which are prevalent in states of insulin resistance, are thought to be more likely to commit Cholesterol Crimes in the arterial wall compared to large buoyant LDL particles (lbLDL-P).  And, along with the metabolic milieu that typically results in these small particles predominating, there are a bunch of characteristics that potentially make the sdLDL less likely to be cleared from circulation and more likely to be retained in the arterial wall (you can read more about these characteristics in THIS BOOK and more about Advanced Lipid Panels in THIS ARTICLE).  However, thinking you’re invincible because you have “Pattern A” full of large fluffy LDL is “A for Asinine” if you haven’t addressed all the other components in a full Home Security System and Lipid Neighborhood Risk Stratification-style workup.

But this recent publication on Large/Small particles in a LARGE 21,382 patient cohort with coronary artery disease treated with statins and followed over ~3 years is, at the very least, of SMALL interest.  (Maybe we should call this cohort Blink-21382…or maybe not…no one who actually reads this article is likely listening to 1990s Punk Rock). 

But anyway, instead of obtaining a full NMR spectroscopy of lipid subfractionations, the LDL-C/ApoB ratio was used as a surrogate for small LDL-P in this study.  LDL-C/ApoB above or below 1.2 was used as the cutoff for predominantly large LDL-P (Pattern A) or predominantly small LDL-P (Pattern B for Bad). 

Among those with Type 2 Diabetes in this cohort, an LDL-C/ApoB ratio >1.2 was associated with a 19% reduced risk of major adverse cardiovascular events (MACE) compared to those with predominantly smaller LDL-P (as quantified by an LDL-C/ApoB ratio <1.2).  However, this same effect WAS NOT OBSERVED in those without Type 2 Diabetes.

So maybe we should hold off on playing Blink-182 anthems as “Walk-Up Songs” every time we enter patient rooms.  I still think, at this time, the greatest role for Advanced Lipid Panels is in the true Primary Prevention setting to identify features consistent with insulin resistance.  But although most ratios are useless, maybe LDL-C/ApoB ratio isn’t a completely terrible metric in certain contexts.

However, the likelihood of this article changing lipid management for savvy clinicians is about as likely as your 66 year-old patients with coronary disease and Type 2 Diabetes naming Blink-182’s Dude Ranch as their favorite album😊