From the Guidelines
High lipoprotein(a), or Lp(a), increases your risk of heart disease and stroke, and should be addressed through lifestyle changes and possibly medication, with a focus on achieving Lp(a) levels below 50 mg/dL as recommended by the European Society of Cardiology guidelines 1. To manage high Lp(a) levels, focus on a heart-healthy diet low in saturated fats, regular exercise (aim for 150 minutes weekly of moderate activity), weight management, and avoiding tobacco. While no medications specifically target Lp(a), statins like atorvastatin (20-80mg daily) or rosuvastatin (10-40mg daily) may be prescribed to lower overall cardiovascular risk, as supported by the 2016 ESC/EAS guidelines for the management of dyslipidaemias 1. PCSK9 inhibitors such as evolocumab or alirocumab might be added for those with very high levels or existing heart disease, as suggested by the NHLBI working group recommendations to reduce Lp(a)-mediated risk of cardiovascular disease and aortic stenosis 1. Niacin (1-3g daily) can modestly reduce Lp(a) but has side effects including flushing and liver concerns, as noted in the guidelines for the primary prevention of stroke 1. Lp(a) levels are largely genetic and don't change much with lifestyle, but controlling other risk factors is crucial, and regular monitoring through lipid panels and discussing family history with your doctor is important, as Lp(a) elevation often runs in families and may warrant earlier screening for relatives, as emphasized by the NHLBI working group recommendations 1. Some key points to consider include:
- The European Society of Cardiology guidelines recommend measuring Lp(a) in patients at high risk of cardiovascular disease and targeting levels below 50 mg/dL 1.
- Lp(a) levels are mainly determined by genetic traits and have pro-atherogenic and pro-thrombotic properties, as discussed in the 2016 ESC/EAS guidelines for the management of dyslipidaemias 1.
- The NHLBI working group recommendations suggest that existing and new clinical CVD outcomes studies and trials measure Lp(a) and report their Lp(a)-related outcomes, and that collaborative, patient-level meta-analysis should be performed to define the role of baseline and on-treatment Lp(a) and CVD risk in secondary prevention settings 1.
- Antisense therapy has demonstrated an ability to lower plasma Lp(a) levels by up to 90% or more, even in subjects with greatly elevated Lp(a) levels, as noted in the NHLBI working group recommendations 1. It is essential to work with your doctor to develop a personalized plan to manage your Lp(a) levels and reduce your risk of cardiovascular disease, taking into account the latest research and guidelines, including those from the European Society of Cardiology and the NHLBI working group recommendations 1.
From the Research
High Lipoprotein(a) Levels
If lipoprotein(a) is high, it is considered a risk factor for multiple cardiovascular disease phenotypes, including atherosclerosis and major cardiovascular events 2. Elevated lipoprotein(a) is also associated with non-atherosclerotic endpoints such as venous thromboembolism and calcific aortic valve disease.
Risk Assessment and Stratification
High lipoprotein(a) levels can contribute to residual cardiovascular risk in patients receiving standard-of-care LDL-lowering therapy 2. Therefore, lipoprotein(a) measurements should be considered in patients with premature vascular disease, intermediate and high Framingham risk patients with a family history of premature coronary disease, and low Framingham risk patients with a family history and low high-density lipoprotein cholesterol (HDL-C) levels 3.
Treatment Options
Several treatment options are available to lower lipoprotein(a) levels, including:
- Lipoprotein apheresis (LA), which efficiently lowers lipoprotein(a) and has been associated with a reduction of incident cardiovascular events 2
- PCSK9 inhibitors, which can significantly reduce lipoprotein(a) levels by up to 30% 2
- Antisense oligonucleotides (ASO), which have shown good safety and strong efficacy with up to 90% reductions in lipoprotein(a) levels 2
- Extended-release niacin, which can lower lipoprotein(a) levels when used in combination with other therapies 3, 4
- Ezetimibe, which has been shown to lower lipoprotein(a) levels in some studies 3, 5
Statin Therapy
Statin therapy has been shown to have neutral or detrimental effects on lipoprotein(a) levels 2, 6. A systematic review and meta-analysis found that statin therapy did not lead to clinically important differences in lipoprotein(a) compared to placebo in patients at risk for cardiovascular disease 6. However, some studies have suggested that certain statins, such as rosuvastatin, may be more effective at lowering lipoprotein(a) levels than others 4.
Screening and Monitoring
Selective screening strategies for high-risk patients are recommended, but universal screening of the population is currently not advised 5. Lipoprotein(a) levels should be measured using an apo(a)-isoform independent assay that employs appropriate calibrators and reports the results in molar units (nmol/L) 5. Circulating lipoprotein(a) concentrations should be estimated after accounting for factors such as ancestry, ethnicity, hormones, renal function, and acute inflammatory events 5.