From the Guidelines
Management of elevated LDL and Lp(a) levels is crucial to reduce cardiovascular risk. For a 45-year-old with elevated LDL and Lp(a) levels, the primary goal is to achieve an LDL-C level of <100 mg/dL, and consider further reduction to <70 mg/dL if the patient is at high risk 1.
Key Recommendations
- Lifestyle modifications: Advocate a healthy diet, physical activity, and weight management to reduce LDL-C levels 1.
- Statins as first-line therapy: Initiate statin therapy to lower LDL-C levels, considering the patient's risk factors and LDL-C goals 1.
- Consideration of Lp(a) levels: Measure Lp(a) levels in patients with a strong family history of premature CHD or familial hypercholesterolemia (FH), and consider it as an additional risk factor to justify a lower LDL-C goal 1.
- Monitoring and adjustment: Regularly monitor LDL-C and Lp(a) levels, and adjust treatment as needed to achieve optimal lipid profiles 1.
Additional Considerations
- Risk assessment: Use the ASCVD risk calculator to assess the patient's 10-year risk of cardiovascular events, and consider risk-enhancing factors such as family history, elevated biomarkers, and comorbidities 1.
- Treatment targets: Aim for an LDL-C level of <55 mg/dL in very high-risk patients, and consider non-statin therapies such as ezetimibe or PCSK9 inhibitors if goals are not achieved with statin therapy alone 1.
- Lp(a) lowering therapies: Although there are no currently available therapies specifically targeting Lp(a), emerging therapies such as antisense therapy may offer potential benefits in the future 1.
From the Research
Management Recommendations for Elevated LDL and Lp(a) Levels
The management of a 45-year-old with elevated LDL and Lp(a) levels involves a multi-step approach, focusing on reducing cardiovascular risk. The key recommendations include:
- Aggressive management of traditional cardiovascular risk factors, including LDL-cholesterol (LDL-C) 2
- Reducing LDL-C to the lowest attainable value with a high-potency statin as the primary focus of lipid-modifying therapies 3
- Considering the addition of niacin (up to 2 g/d) if the Lp(a) level is 30 mg/dL or higher and the patient has residual LDL-C elevations (≥70-100 mg/dL) despite maximum-potency statins or combination statin therapy 3
- Contemplating LDL apheresis if the patient has progressive coronary heart disease (CHD) or LDL-C levels of 160-200 mg/dL or higher 3
Role of Lp(a) in Cardiovascular Risk
Lp(a) is a strong and independent cardiovascular risk factor, with elevated levels ≥ 50 mg/dl (≥ 125 nmol/l) estimated to occur in more than 1.5 billion people worldwide 4. The size of the apo(a) isoform is inversely proportional to the blood concentration of Lp(a), and determination of Lp(a) levels is crucial for risk assessment 4.
Treatment Options for Elevated Lp(a) Levels
Treatment options for elevated Lp(a) levels include:
- Niacin, which has been documented to reduce Lp(a) by 36% to 38% 5
- Ezetimibe, which may have some effect on Lp(a) levels, although the exact mechanism of action is unknown 5
- Proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i), which have been highlighted as a potential role in the management of patients with elevated Lp(a) 2
- Aspirin in primary prevention and prolonged dual antiplatelet therapy in secondary prevention, which may also be considered in the management of patients with elevated Lp(a) 2
Testing and Referral Practices
Testing practices for Lp(a) levels are increasing, with a significant rise in the frequency of incident Lp(a) testing among increased-risk patients over a 5-year period 6. However, the frequency of testing remains low, and future work should target appropriate population-based Lp(a) testing strategies and clinical decision-making regarding risk management once Lp(a) elevation is diagnosed 6. Referral to cardiology or lipid specialist and prescription of new lipid-lowering medication are also important considerations in the management of patients with elevated Lp(a) levels 6.