At what age would you start managing elevated Lipoprotein(a) (Lp(a)) levels?

Management of Elevated Lipoprotein(a) Levels: When to Start

Screening for elevated Lipoprotein(a) [Lp(a)] should begin as early as age 2 years in children with a family history of premature cardiovascular disease (CVD) or significant hypercholesterolemia, and management should be initiated based on risk stratification and age-specific criteria. 1

Screening Recommendations by Age Group

Children and Adolescents

• In children and adolescents with a family history of early CVD or significant hypercholesterolemia, measure fasting or non-fasting lipoprotein profile (including Lp(a)) as early as age 2 years to detect familial hypercholesterolemia (FH) or rare forms of hypercholesterolemia 1
• For children without cardiovascular risk factors or family history of early CVD, it may be reasonable to measure lipid profile once between ages 9-11 years and again between ages 17-21 years 1
• When elevated Lp(a) is detected in children, reverse-cascade screening of family members is reasonable to detect familial forms of hypercholesterolemia 1

Adults

• Screening for Lp(a) is not recommended for primary prevention unless:
  • Unexplained early cardiovascular events have occurred in first-degree relatives, OR
  • High Lp(a) is known to be present in first-degree relatives 1
• Lp(a) should be measured in adults with:
  • Intermediate or high CVD/CHD risk
  • Premature CVD
  • Familial hypercholesterolemia
  • Family history of premature CVD and/or elevated Lp(a)
  • Recurrent CVD despite statin treatment
  • ≥3% 10-year risk of fatal CVD or ≥10% 10-year risk of fatal + non-fatal CHD 2

Management Approach Based on Age and Risk Factors

Children and Adolescents with Elevated Lp(a)

• For children age <10 years: Focus on lifestyle interventions only 1
• For children age ≥10 years with elevated Lp(a) and LDL-C persistently ≥160 mg/dL:
  • Begin with 3-6 months of lifestyle therapy
  • If inadequate response, consider statin therapy 1
• For children age ≥10 years with elevated Lp(a) and LDL-C ≥130 mg/dL with additional risk factors:
  • Consider statin therapy after 6 months of lifestyle intervention 1

Adults with Elevated Lp(a)

• The cornerstone of management is aggressive treatment of traditional cardiovascular risk factors, particularly LDL-C 3
• Desirable level for Lp(a) should be <80th percentile (less than ~50 mg/dL) 2
• Treatment approach:
  • Primary focus should be on LDL-C reduction
  • Consider Lp(a) as a risk enhancer to guide medical care and shared decision-making 3
  • In patients with elevated Lp(a) and family history of CVD, more aggressive risk factor management is warranted as these factors have independent and additive joint associations with cardiovascular risk 4

Risk Assessment and Treatment Algorithm

1. Measure Lp(a) once using an isoform-insensitive assay in individuals with:

   • Family history of premature CVD
   • Personal history of premature CVD
   • Familial hypercholesterolemia
   • Recurrent CVD despite statin treatment 2

2. Risk stratification:

   • Calculate 10-year ASCVD risk using Pooled Cohort Equations
   • Consider coronary artery calcium (CAC) scoring for further risk assessment in adults with borderline or intermediate risk 5
   • Elevated Lp(a) plus family history of CVD places individuals in a higher risk category 4

3. Treatment approach based on risk:

   • Low risk: Lifestyle modifications
   • Intermediate risk: Aggressive management of traditional risk factors; consider statin therapy
   • High risk: Intensive statin therapy; consider PCSK9 inhibitors 3

Clinical Pearls and Pitfalls

• Lp(a) levels are genetically determined and minimally impacted by lifestyle modifications or standard lipid-lowering drugs 6
• The concentration attained in adulthood is already present in children around 5 years of age, highlighting the importance of early screening in high-risk families 6
• When screening for FH, consider concurrent screening for Lp(a) as the combination of elevated Lp(a) and FH significantly increases cardiovascular risk 7
• Avoid the common pitfall of not measuring Lp(a) in patients with recurrent cardiovascular events despite optimal LDL-C control 3, 2
• Remember that elevated Lp(a) is actionable today through aggressive management of other risk factors, even while specific Lp(a)-lowering therapies are still under development 3