Lipid Ratio Plot: A Simple Graphical Approach for Investigating the Accuracy of LDL Cholesterol Equations or Direct...

β-Quantification (BQ) is the reference method for low-density lipoprotein cholesterol (LDL-C) determination. It is not widely available, making it challenging for laboratories to assess the accuracy of LDL-C methods. Our goal was to develop an indirect graphical approach for comparing LDL-C test results to the BQ reference method.

BQ results from Mayo Medical Laboratories (n = 39 969) and the National Institutes of Health (n = 17 825) were used to investigate the interrelationships between lipid panel tests. A plot of LDL-C/non high-density lipoprotein cholesterol (nonHDL-C) vs (triglyceride (TG)/nonHDL-C)0.5 (lipid ratio plot) resulted in a negative linear regression line (y = -34.2x + 115). Based on simulation analysis, the minimum sample size for calculating its slope and intercept with a coefficient of variation of about 7.5% was 80.

The regression lines for the lipid ratio plot of LDL-C calculated by the Sampson-NIH (y = -37.6x + 118) and enhanced Sampson-NIH (y = -33.1x + 116) equations closely overlapped with the BQ method. In contrast, the Martin-Hopkins equation showed a positive bias with an increasing TG/nonHDL-C ratio and exceeded the recommended bias limit of 4% on hypertriglyceridemic samples (y = -25.5x + 107). The Friedewald equation showed an even larger negative bias with hypertriglyceridemia (y = -47.5x + 126). Lipid ratio plots of the Roche direct assay revealed a fixed positive bias of approximately 4% (y = -33.9x + 120), whereas a much larger proportional positive bias was observed with increasing triglycerides for the Beckman direct assay (y = -14.6x + 97.8).

The lipid ratio plot is a simple graphical approach that can be readily performed by clinical laboratories for investigating the accuracy of LDL-C assays by calculation methods or direct assays.