Lipoprotein (a), a genetically inherited cholesterol particle, is a significant independent risk factor for heart disease. It shares a common protein on its surface, ApoB-100, with low-density lipoprotein (LDL), commonly known as “bad” cholesterol. However, Lp(a) possesses an additional side chain, apo(a), distinguishing it from LDL. Lipoprotein(a) has also been referred to as “stealth cholesterol” because conventional lipid testing typically fails to detect or quantify this particle.
Increased Risk of Cardiovascular Disease
High Lp(a) levels substantially elevate the risk of various cardiovascular conditions. Here’s how:
- Plaque Buildup:All apoB-containing particles contribute to plaque formation in blood vessel walls. These plaques can narrow arteries, reducing blood flow to vital organs such as the heart, brain, kidneys, and peripheral arteries.
- Clotting and Inflammation:The apo(a) side chain is believed to promote clotting and inflammation. High Lp(a) levels (specifically, 50 mg/dL or 125 nmols/L or higher) enhance these processes.
- Increased Risk of Conditions:These factors can lead to severe conditions, including heart attack, stroke, aortic stenosis, and peripheral artery disease.
Testing for Lp(a) and Frequency
Many individuals with high Lp(a) do not experience symptoms until a serious event such as a heart attack or stroke occurs. Therefore, it is essential to consult your healthcare professional about Lp(a) testing if you exhibit any of the following indicators:
- Family History of High Lp(a) or Early Development of Heart Disease: Before age 55 for men or age 65 for women.
- Familial Hypercholesterolemia (FH):An inherited condition affecting the body’s ability to process LDL (“bad” cholesterol); approximately one-third of individuals with FH also have high Lp(a).
- Personal or Family History of Heart Attack, Stroke, or Coronary Artery Disease: Before age 55 for men or age 65 for women.
- Poor Circulation in Legs:Due to peripheral arterial disease.
- Diagnosis of Aortic Stenosis
Regarding the frequency of testing for Lp(a) levels, it is important to note that once a level is obtained, it remains stable. Consequently, medical professionals recommend that most individuals should have their Lp(a) levels assessed at least once throughout their lifetime, ideally in their early twenties, particularly if there is a family history of coronary heart disease.
An abnormal Lp(a) level is generally defined as exceeding 50 mg/dL (or 125 nmol/L). It is worth mentioning that Lp(a) levels can be expressed in different units, such as milligrams per deciliter (mg/dL) or nanomoles per liter (nmol/L).
Regarding the impact of age on Lp(a) levels, genetics play a primary role in determining them. Once a level is established, it tends to remain consistent thereafter. However, certain life stages or conditions, such as menopause, can potentially increase Lp(a) levels.
How does my physician utilize the information regarding elevated Lp(a) in my evaluation?
Identifying potential risk factors for high Lp(a) levels involves a comprehensive evaluation. In addition to symptoms (or the absence thereof) and personal/family history, genetics are the primary determinant of risk.
Ethnicity and other factors can also influence an individual’s risk of high Lp(a).
Ethnicity: While high Lp(a) levels are prevalent among individuals of all races, South Asian and Black people of African descent frequently exhibit the highest levels. The underlying cause of this disparity remains elusive.
Familial Hypercholesterolemia (FH): Individuals diagnosed with FH are more susceptible to developing high Lp(a) levels.
Kidney Disease: Individuals with kidney disease are also more likely to have elevated Lp(a) levels.
Inflammatory Diseases: These conditions have been associated with elevated Lp(a) levels.
Hypothyroidism: This medical condition often correlates with elevated Lp(a) levels, which tend to decrease with the improvement of the condition.
Sex and Age: Studies have demonstrated that women aged 50 and above exhibit higher Lp(a) levels compared to men.
How Will My Doctor Utilize This Information for Evaluation and Treatment?
If you have a high Lp(a) level, your doctor will employ this information to more aggressively manage your other cardiovascular risk factors, despite the fact that Lp(a) itself is not influenced by lifestyle modifications.
Intensive Risk Factor Management: Your doctor will strive to achieve lower LDL cholesterol targets. They may intensify blood pressure management and encourage lifestyle changes such as maintaining a healthy body weight, regular exercise, and abstaining from smoking.
Lifestyle Changes: These encompass staying physically active, consuming a nutritious diet, ensuring adequate sleep, avoiding smoking, and maintaining a healthy body mass index (BMI).
Elevated Lp(a) Treatment Options for Young Asymptomatic Patients and Patients with Known Cardiovascular Disease
Young Asymptomatic Patients (Primary Prevention):
- For patients who have not experienced a heart attack or stent (primary prevention) but have high Lp(a) and a strong family history or elevated coronary calcium score, aggressive management of other risk factors is essential.
- This includes optimizing diet (e.g., Mediterranean diet), ensuring regular exercise, using the highest potency statin available, often adding ezetimibe (Zetia) to further lower LDL, and considering aspirin.
- In severe cases where LDL cannot be lowered sufficiently, injectable PCSK9 inhibitors may be considered, although insurance coverage for these treatments can be challenging.
Patients with Known Cardiovascular Disease (Secondary Prevention):
- For patients who have already experienced a heart attack or other cardiovascular event and have high Lp(a), treatment goals are even more aggressive.
- Lower LDL Targets:The objective for LDL cholesterol is significantly lower, ideally less than 55 mg/dL, and some specialists aim for even lower levels, such as the mid-30s.
- Intensified Medication: This often entails adding a PCSK9 inhibitor to high-dose statin therapy, as statins alone are typically insufficient to attain these aggressive LDL targets, particularly with elevated Lp(a).
Medications for Reducing Lp(a):
- Statins: Statin medications do not lower Lp(a) levels. While they are essential for lowering overall cholesterol and reducing the risk of heart attack and stroke, they do not directly impact Lp(a).
- PCSK9 Inhibitors:These injectable medications can reduce Lp(a) levels to some extent. However, the clinical significance of Lp(a) lowering by this medication remains uncertain.
Lifestyle Factors Affecting Lp(a):
It is a common misconception that lifestyle changes can affect Lp(a) levels.
- Fact: Lifestyle changes do not influence Lp(a) levels. This is because Lp(a) levels are primarily determined by genetics.
- Importance of Healthy Lifestyle:Although lifestyle changes do not lower Lp(a), maintaining a healthy lifestyle remains crucial for lowering overall heart disease risk and managing other risk factors.
Other Medications Under Investigation for Reducing Lp(a):
New treatments specifically designed to lower Lp(a) levels are currently under investigation and could become available in the near future.
Promising Therapies and Drug Candidates: Pelacarsen and Olpasiran are currently undergoing testing for Lp(a) lowering and reduction in cardiovascular events.
Vital Heart and Vein is actively participating in a clinical trial of Olpasiran for preventing the first major cardiovascular event in patients with elevated Lp(a) levels ≥200 nmol/L. Potential subjects may contact our Research Director, Dr. Shamnum Muhebb, at 281-572-0109, for further information.
Curious About Your Lipoprotein(a)?
Lipoprotein(a) is a powerful but often overlooked driver of cardiovascular risk—yet a simple, once-in-a-lifetime blood test can clarify your inherited risk and guide a plan that truly protects your heart. If you’re curious about your Lipoprotein(a) level, or you have a personal or family history of early heart disease or stroke, call Vital Heart & Vein to speak with our team, or request an appointment today. We’ll help you understand your numbers, tailor a prevention or treatment strategy, and connect you with the right services—including Preventive Cardiology and Cholesterol Management—so you can move forward with confidence.
