Analyses & Studies
Focus Healthcare: Lipoprotein (a), knowing whether it is elevated may help prevent a heart attack
A cautionary tale
Mr. L, a 37-year-old male complained of recurrent exertional chest pain which was getting progressively worse. He was subsequently found to have a heart attack, which was due to a severely blocked (95% stenosis) left anterior descending coronary artery, for which he had urgent coronary balloon and stenting performed in order to restore blood flow to the heart.
On first glance Mr. L appeared to be a young healthy individual who did not smoke and was not overweight. He did not have hypertension, diabetes or elevated cholesterol levels. There was however a family history of heart disease; his mother had a coronary artery bypass grafting surgery done in her early sixties for heart disease. Overall Mr. L would not be considered at high risk for premature heart disease, so how could we have avoided his heart attack? If you think having a normal or low cholesterol level means you won’t have heart disease, think again! Mr. L was found to have elevated Lipoprotein (a) levels, or Lp(a) for short.
What is Lp(a) and why does this matter to our health?
Lp(a) is a type of cholesterol-carrying particle in the blood that is similar to LDL ("bad") cholesterol but is even more likely to cause heart attacks and strokes. Elevated Lp(a) levels can increase this risk even in individuals with normal or low LDL cholesterol levels. This is because in addition to getting more easily into the blood vessel wall to cause blockages, it also promotes inflammation and blood clotting.
High levels of Lp(a) are genetically determined and occurs more commonly than we think, affecting around one in five people. At present Lp(a) testing is not routinely performed, but there are increasing calls to include it during routine cholesterol screening. More so in individuals with artery blockages at a young age, or have a family history of early heart disease or stroke, or high cholesterol that doesn’t respond to treatment.
What can we do if we have elevated Lp(a) levels?
Currently there is no drug treatment yet, but there are several promising candidates undergoing research. Although healthy changes to diet and exercise don’t significantly lower Lp(a) levels, these measures are still important because they can still lower one’s overall cardiovascular risk. Beneficial measures include smoking cessation, regular exercise and eating a heart healthy diet such as a DASH or Mediterranean diet. Maintain a healthy weight (Body mass index or BMI<25), alleviating one’s stress and ensuring adequate quality sleep. Traditional risk factors such as hypertension, diabetes or high cholesterol when present must be strictly controlled and the threshold to use medications to achieve optimal control should be lowered. Furthermore, blood thinners may be recommended in some patients, and in more severe cases even apheresis, which acts like dialysis to extract Lp(a) out of the blood thereby reducing its level.
Presently, many people are unaware of their Lp(a) levels, as it doesn't typically cause noticeable symptoms. Knowing your Lp(a) level can help you and your doctor make more informed decisions on how to better manage your risk of heart attack and stroke. If Mr. L had known of his raised Lp(a) sooner, it is likely that he would have had earlier screening for heart disease, which would then have resulted in it being detected and treated before he could have a heart attack. Check with your doctor if you should screen for elevated Lp(a) today.
By Dr Peter Ting, Senior Consultant Cardiologist, Harley Street Heart & Vascular Centre
