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Emerging From the Shadows: Lp(a) - American College of Cardiology
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What Gets Measured Gets Managed
When should clinicians measure Lp(a)? A lot more often than they do now, according to the experts.
"If you go into the coronary care unit and see someone who is 40 years old with an acute myocardial infarction (MI), you need to know the level of their Lp(a), because those are the people who have Lp(a) levels of 200 and 300 mg/dL or even higher," says Steven E. Nissen, MD, MACC.
Nissen is the chief academic officer at the Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, and holds the Lewis and Patricia Dickey Chair in Cardiovascular Medicine at the Cleveland Clinic.
There are three compelling reasons to obtain at least a one-time measurement of Lp(a) in most patients, suggests Ference, even though at present there is no effective means to lower it.
Of note, all three reasons are integrated into a new guideline for managing Lp(a) from the European Society of Atherosclerosis and scheduled to be released at its meeting in late May. Ference is an author of the guideline.
"One, Lp(a) needs to be measured so it can be included in new algorithms to estimate exactly how much Lp(a) increases risk, and by extension, the degree of benefit from lowering it when a therapy becomes available," says Ference.
Two, after the level of increased risk from elevated Lp(a) is better understood, it is possible to minimize the Lp(a)-related risk, despite no real decrease in the Lp(a) level, by intensifying risk factor modification. This will be addressed in the new EAS guideline with an algorithm that will help clinicians understand how much the risk is increased and how much to intensify treatment, for example with additional lowering of LDL-C or blood pressure. Currently, there is little guidance, and "we need more specific and actionable information" says Ference.
Three, measuring Lp(a) will help increase awareness among family members. By most estimates, elevated Lp(a) is inherited in 70% to 90% of cases. Considering the high likelihood that a child or other family member also could have high levels of Lp(a), this awareness and testing can lead to earlier treatment and intensification of lowering LDL-C and blood pressure to prevent ASCVD. And potentially lead to treatment with new therapies when they become available.
Cumulative lifetime exposure to higher levels of LDL-C determines cardiovascular risk, according to Mendelian randomization studies. While this is also believed to be true for Lp(a), this has not been proven yet.
If the trials of Lp(a) show the benefit of lowering it starting later in life is smaller than the benefit of lifelong lowering of LDL-C, "we can conclude the effect of elevated Lp(a) levels increases over time just like for LDL-C," explains Ference. Because Lp(a) is largely inherited, this could lead to a recommendation to measure it early in life, perhaps in the teens, to identify those at "very high risk." And provide an earlier start to reducing risk by getting LDL-C levels really low, controlling other risk factors very well, and "hopefully one day soon, treat their Lp(a)," Ference says.
https://www.acc.org/latest-in-cardiology/articles/2022/05/01/01/42/cover-story-emerging-from-the-shadows-lp-a
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