Lipoprotein(a) - Cardiovascular Risk Factor
Lipoprotein(a) is a blood lipid particle that is largely determined by genetics and can significantly increase the risk of cardiovascular disease.
Things worth knowing about "Lipoprotein a"
Lipoprotein(a) is a blood lipid particle that is largely determined by genetics and can significantly increase the risk of cardiovascular disease.
What is Lipoprotein(a)?
Lipoprotein(a), commonly abbreviated as Lp(a), is a unique lipoprotein particle found in the blood. It consists of an LDL-like core particle bound to an additional protein called apolipoprotein(a). Lp(a) is considered an independent risk factor for cardiovascular disease and its blood concentration is largely determined by genetics -- diet and lifestyle have minimal influence on its levels.
Causes of Elevated Lp(a) Levels
More than 90% of the variation in Lp(a) levels is genetically determined and can differ significantly between populations. Some factors that may influence levels include:
- Genetic predisposition: Variants in the LPA gene are the primary driver of elevated Lp(a) concentrations.
- Ethnic background: Individuals of African descent tend to have higher average Lp(a) levels.
- Chronic kidney disease: Reduced kidney function is associated with increased Lp(a) levels.
- Hypothyroidism: An underactive thyroid gland can raise Lp(a) levels.
- Menopause: Hormonal changes during menopause are associated with rising Lp(a) concentrations.
Why is Lipoprotein(a) Dangerous?
Elevated Lp(a) promotes the development of atherosclerosis (hardening and narrowing of the arteries) and simultaneously impairs the natural breakdown of blood clots (fibrinolysis), because apolipoprotein(a) structurally resembles plasminogen, a key protein in clot dissolution. This dual mechanism raises the risk of:
- Heart attack (myocardial infarction)
- Stroke
- Peripheral artery disease (PAD)
- Aortic valve stenosis
Diagnosis
Lp(a) levels are measured through a standard blood test. Current guidelines recommend at least one measurement during a lifetime, particularly for individuals with:
- A family history of premature cardiovascular disease
- Familial hypercholesterolaemia
- Recurrent cardiovascular events despite optimal therapy
- Elevated overall cardiovascular risk
An Lp(a) level below 30 mg/dl (or below 75 nmol/l) is generally considered normal. Values above 50 mg/dl are considered significantly elevated and are associated with a substantially increased cardiac risk.
Treatment Options
Directly lowering Lp(a) with medication has historically been challenging, as conventional lipid-lowering drugs such as statins have little effect on Lp(a) levels. Current and emerging treatment options include:
- PCSK9 inhibitors: Monoclonal antibodies such as evolocumab and alirocumab can moderately reduce Lp(a) by approximately 20--30%.
- Lipoprotein apheresis: An extracorporeal blood-cleansing procedure used in patients with very high Lp(a) levels and established cardiovascular disease, capable of significantly reducing Lp(a) concentrations.
- RNA-based therapies (in development): Antisense oligonucleotides such as pelacarsen and siRNA-based agents such as olpasiran have shown reductions of up to 80--90% in clinical trials.
- General cardiovascular risk management: Blood pressure control, smoking cessation, diabetes management, and LDL reduction remain essential components of treatment.
References
- Nordestgaard BG et al. - Lipoprotein(a) as cardiovascular risk factor: current status. European Heart Journal, 2010; 31(23): 2844--2853.
- ESC/EAS Guidelines for the management of dyslipidaemias. European Heart Journal, 2019; 40(40): 3307--3397.
- Tsimikas S. - A Test in Context: Lipoprotein(a): Diagnosis, Prognosis, Controversies, and Emerging Therapies. Journal of the American College of Cardiology, 2017; 69(6): 692--711.
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