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Cesaro A, Schiavo A, Moscarella E, Coletta S, Conte M, Gragnano F, Fimiani F, Monda E, Caiazza M, Limongelli G, D'Erasmo L, Riccio C, Arca M, Calabrò P. Lipoprotein(a): a genetic marker for cardiovascular disease and target for emerging therapies. J Cardiovasc Med (Hagerstown) 2021; 22:151-161. [PMID: 32858625 DOI: 10.2459/jcm.0000000000001077] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Lipoprotein(a) [Lp(a)] is an established cardiovascular risk factor, and growing evidence indicates its causal association with atherosclerotic disease because of the proatherogenic low-density lipoprotein (LDL)-like properties and the prothrombotic plasminogen-like activity of apolipoprotein(a) [apo(a)]. As genetics significantly influences its plasma concentration, Lp(a) is considered an inherited risk factor of atherosclerotic cardiovascular disease (ASCVD), especially in young individuals. Moreover, it has been suggested that elevated Lp(a) may significantly contribute to residual cardiovascular risk in patients with coronary artery disease and optimal LDL-C levels. Nonetheless, the fascinating hypothesis that lowering Lp(a) could reduce the risk of cardiovascular events - in primary or secondary prevention - still needs to be demonstrated by randomized clinical trials. To date, no specific Lp(a)-lowering agent has been approved for reducing the lipoprotein levels, and current lipid-lowering drugs have limited effects. In the future, emerging therapies targeting Lp(a) may offer the possibility to further investigate the relation between Lp(a) levels and cardiovascular outcomes in randomized controlled trials, ultimately leading to a new era in cardiovascular prevention. In this review, we aim to provide an updated overview of current evidence on Lp(a) as well as currently investigated therapeutic strategies that specifically address the reduction of the lipoprotein.
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Affiliation(s)
- Arturo Cesaro
- Department of Translational Medical Sciences, University of Campania 'Luigi Vanvitelli', Naples
- Division of Clinical Cardiology, A.O.R.N. 'Sant'Anna e San Sebastiano', Caserta
| | - Alessandra Schiavo
- Department of Translational Medical Sciences, University of Campania 'Luigi Vanvitelli', Naples
- Division of Clinical Cardiology, A.O.R.N. 'Sant'Anna e San Sebastiano', Caserta
| | - Elisabetta Moscarella
- Department of Translational Medical Sciences, University of Campania 'Luigi Vanvitelli', Naples
- Division of Clinical Cardiology, A.O.R.N. 'Sant'Anna e San Sebastiano', Caserta
| | - Silvio Coletta
- Department of Translational Medical Sciences, University of Campania 'Luigi Vanvitelli', Naples
- Division of Clinical Cardiology, A.O.R.N. 'Sant'Anna e San Sebastiano', Caserta
| | - Matteo Conte
- Department of Translational Medical Sciences, University of Campania 'Luigi Vanvitelli', Naples
- Division of Clinical Cardiology, A.O.R.N. 'Sant'Anna e San Sebastiano', Caserta
| | - Felice Gragnano
- Department of Translational Medical Sciences, University of Campania 'Luigi Vanvitelli', Naples
- Division of Clinical Cardiology, A.O.R.N. 'Sant'Anna e San Sebastiano', Caserta
| | - Fabio Fimiani
- Division of Cardiology
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania 'Luigi Vanvitelli', Monaldi Hospital, Naples
| | - Emanuele Monda
- Division of Clinical Cardiology, A.O.R.N. 'Sant'Anna e San Sebastiano', Caserta
- Division of Cardiology
| | - Martina Caiazza
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania 'Luigi Vanvitelli', Monaldi Hospital, Naples
| | - Giuseppe Limongelli
- Department of Translational Medical Sciences, University of Campania 'Luigi Vanvitelli', Naples
- Division of Cardiology
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania 'Luigi Vanvitelli', Monaldi Hospital, Naples
| | - Laura D'Erasmo
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Carmine Riccio
- Division of Clinical Cardiology, A.O.R.N. 'Sant'Anna e San Sebastiano', Caserta
| | - Marcello Arca
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Paolo Calabrò
- Department of Translational Medical Sciences, University of Campania 'Luigi Vanvitelli', Naples
- Division of Clinical Cardiology, A.O.R.N. 'Sant'Anna e San Sebastiano', Caserta
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Watanabe J, Hamasaki M, Kotani K. The Effect of Helicobacter pylori Eradication on Lipid Levels: A Meta-Analysis. J Clin Med 2021; 10:jcm10050904. [PMID: 33668848 PMCID: PMC7956592 DOI: 10.3390/jcm10050904] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Revised: 02/18/2021] [Accepted: 02/21/2021] [Indexed: 12/23/2022] Open
Abstract
Introduction:Helicobacter pylori (H. pylori) infection is positively associated with cardiovascular diseases, but the involvement of lipids in this association remains unclear. The present study reviewed the changes in circulating lipid levels following H. pylori eradication. Methods: A PubMed database was searched until December 2020 to identify randomized control trials (RCTs) and non-RCTs investigating the effect of H. pylori eradication on the lipid levels in inverse variance-weighted, random-effects meta-analyses. Results: A total of 24 studies (four RCTs and 20 non-RCTs) with 5270 participants were identified. The post-eradication levels were increased for high-density lipoprotein cholesterol (HDL-C; mean difference (MD) 2.28 mg/dL, 95% confidence interval (CI) 1.90 to 2.66) and triglyceride (TG; MD 3.22 mg/dL, 95% CI 1.13 to 5.31) compared with the pre-eradication levels. H. pylori eradication resulted in little to no difference in the low-density lipoprotein-cholesterol levels (MD −2.33 mg/dL, 95% CI −4.92 to 0.26). In the analyses of RCTs only, the findings for elevated HDL-C levels, but not TG, were robust. Conclusions:H. pylori eradication increases the HDL-C levels. Further studies are needed to elucidate the effects of lipid changes following H. pylori eradication on cardiovascular diseases.
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Affiliation(s)
| | | | - Kazuhiko Kotani
- Correspondence: ; Tel.: +81-285-58-7394; Fax: +81-285-44-0628
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Patel AP, Wang M, Pirruccello JP, Ellinor PT, Ng K, Kathiresan S, Khera AV. Lp(a) (Lipoprotein[a]) Concentrations and Incident Atherosclerotic Cardiovascular Disease: New Insights From a Large National Biobank. Arterioscler Thromb Vasc Biol 2021; 41:465-474. [PMID: 33115266 PMCID: PMC7769893 DOI: 10.1161/atvbaha.120.315291] [Citation(s) in RCA: 84] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Lp(a) (lipoprotein[a]) concentrations are associated with atherosclerotic cardiovascular disease (ASCVD), and new therapies that enable potent and specific reduction are in development. In the largest study conducted to date, we address 3 areas of uncertainty: (1) the magnitude and shape of ASCVD risk conferred across the distribution of lipoprotein(a) concentrations; (2) variation of risk across racial and clinical subgroups; (3) clinical importance of a high lipoprotein(a) threshold to guide therapy. Approach and Results: Relationship of lipoprotein(a) to incident ASCVD was studied in 460 506 middle-aged UK Biobank participants. Over a median follow-up of 11.2 years, incident ASCVD occurred in 22 401 (4.9%) participants. Median lipoprotein(a) concentration was 19.6 nmol/L (25th-75th percentile 7.6-74.8). The relationship between lipoprotein(a) and ASCVD appeared linear across the distribution, with a hazard ratio of 1.11 (95% CI, 1.10-1.12) per 50 nmol/L increment. Substantial differences in concentrations were noted according to race-median values for white, South Asian, black, and Chinese individuals were 19, 31, 75, and 16 nmol/L, respectively. However, risk per 50 nmol/L appeared similar-hazard ratios of 1.11, 1.10, and 1.07 for white, South Asian, and black individuals, respectively. A high lipoprotein(a) concentration defined as ≥150 nmol/L was present in 12.2% of those without and 20.3% of those with preexisting ASCVD and associated with hazard ratios of 1.50 (95% CI, 1.44-1.56) and 1.16 (95% CI, 1.05-1.27), respectively. CONCLUSIONS Lipoprotein(a) concentrations predict incident ASCVD among middle-aged adults within primary and secondary prevention contexts, with a linear risk gradient across the distribution. Concentrations are variable across racial subgroups, but the associated risk appears similar.
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Affiliation(s)
- Aniruddh P. Patel
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, Massachusetts
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, Massachusetts
| | - Minxian Wang
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, Massachusetts
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, Massachusetts
| | - James P. Pirruccello
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, Massachusetts
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, Massachusetts
| | - Patrick T. Ellinor
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, Massachusetts
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, Massachusetts
| | - Kenney Ng
- Center for Computational Health, IBM Research, Cambridge, Massachusetts
| | - Sekar Kathiresan
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, Massachusetts
- Verve Therapeutics, Cambridge, Massachusetts
| | - Amit V. Khera
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, Massachusetts
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, Massachusetts
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54
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Should Lipoprotein(a) be Measured in Youth? J Pediatr 2021; 228:285-289. [PMID: 32822740 DOI: 10.1016/j.jpeds.2020.08.042] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 08/12/2020] [Accepted: 08/14/2020] [Indexed: 01/06/2023]
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Clark D, Puri R, Nissen SE. Coronary atherosclerotic plaque progression: contributing factors in statin-treated patients. Expert Rev Cardiovasc Ther 2020; 18:873-880. [DOI: 10.1080/14779072.2020.1833716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Donald Clark
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Rishi Puri
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Steven E. Nissen
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
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Prevalence and status of Lipoprotein (a) among Lebanese school children. Sci Rep 2020; 10:20620. [PMID: 33244019 PMCID: PMC7692560 DOI: 10.1038/s41598-020-77689-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 11/13/2020] [Indexed: 12/24/2022] Open
Abstract
Lipoprotein a (Lp(a) is an independent risk factor for atherosclerotic cardiovascular disease. The prevalence of high Lipoprotein (a) (Lp(a)) in the Lebanese pediatric population is unknown. Our study aims to assess this prevalence and to study the relationship of Lp(a) with the lipid profile, age, body mass index (BMI) and socio-economic status (SES) in Lebanese schoolchildren. A total of 961 children aged 8–18 years (497 boys and 464 girls) were recruited from ten private and public schools in 2013–2014 using a stratified random sample. Schools were selected from the Greater Beirut and Mount Lebanon areas, and were categorized into three subgroups according to the schools’ SES status (high, medium, low). Lp(a) was assayed in 2018 on samples previously frozen at − 80 °C. Abnormal Lp(a) levels (≥ 75 nmol/L) were observed in 14.4% of the overall sample (13.5% for boys,15.3% of girls p = 0.56). The median of Lp(a) was 20(10–50) in the whole sample with no significant gender difference. No significant relationship was found between Lp(a) and age. However, Lp(a) was significantly correlated with BMI in whole sample, as well as in boys and girls (p = 0.02, p = 0.03, p = 0.03, respectively). A significant correlation was found between Lp(a) and non-HDL-C in the whole sample as well as in boys and girls (respectively p < 0.001,p = 0.024 and p = 0.03), but not with triglycerides and HDL-C. In a multivariate linear regression analysis, Lp(a) was only independently associated with BMI and non-HDL-C in boys and girls. Lp(a) was independently associated with BMI and non-HDL-C while no significant relationship was observed with age and sex confirming the strong genetic determination of Lp(a).
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Abstract
Compelling evidence has emerged from epidemiological and Mendelian randomization analyses relative to the causality of lipoprotein(a) [Lp(a)] in atherosclerotic cardiovascular diseases (ASCVD), being elevated Lp(a) a strong risk factor regardless of the reduction of LDL-C achieved by statins. So far, no specific available agent can lower Lp(a) to the extent required to achieve a cardiovascular (CV) benefit, i.e. approximately 100 mg/dL. The most recent outcomes trial FOURIER with evolocumab showed that a 25 nmol/L (12 mg/dL) reduction in Lp(a) corresponded to a 15% decrement in the relative risk of cardiovascular disease. The ODYSSEY OUTCOMES trial with alirocumab has been the first demonstrating that a reduction in Lp(a) associates with less major adverse cardiovascular events (MACE), i.e. hazard ratio: 0.994 per 1 mg/dL decrement in Lp(a). The Lp(a) lowering effect driven by PCSK9 inhibition was confirmed in carriers of PCSK9 loss-of-function mutations in which Lp(a) and oxPL-apoB levels were decreased compared to non-carriers as was for a slight larger number of apo(a) Kringle IV repeats. Although PCSK9 inhibitors are not able to decrease Lp(a) to the extent required to achieve a CV benefit, their use has led to a higher discontinuation rate in lipoprotein apheresis in patients with progressive ASCVD and high plasma Lp(a).
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Affiliation(s)
- Massimiliano Ruscica
- Dipartimento di Science Farmacologiche e Biomolecolari, Università degli Studi di Milano, Milan, Italy
| | - Maria Francesca Greco
- Dipartimento di Science Farmacologiche e Biomolecolari, Università degli Studi di Milano, Milan, Italy
| | - Nicola Ferri
- Dipartimento di Scienze del Farmaco, Università degli Studi di Padova, Padua, Italy
| | - Alberto Corsini
- Dipartimento di Science Farmacologiche e Biomolecolari, Università degli Studi di Milano, Milan, Italy.,IRCCS, Multimedica, Milan, Italy
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58
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Wu B, Zhao H, Liu C, Lu H, Liu R, Long J, Zhang Z, Zeng F. Association of lipoprotein (a) and in-hospital outcomes in patients with acute coronary syndrome undergoing percutaneous coronary intervention. Postgrad Med 2020; 133:195-201. [PMID: 33131368 DOI: 10.1080/00325481.2020.1845517] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Objective: The current study was to evaluate the association of Lipoprotein (a) [Lp(a)] and in-hospital outcomes in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI).Methods: ACS patients undergoing PCI were retrospectively enrolled. Based on Lp(a) level, patients were divided into low (<30 mg/dL) and high (≥30 mg/dL) Lp(a) groups.Results: Compared to those with low Lp(a), patients with high Lp(a) had larger numbers of coronary arteries ≥70% stenosis and had longer coronary artery lesion (P < 0.05). After adjustment for covariates, high Lp(a) remained associated with higher odds of having coronary artery ≥70% stenosis, type C coronary lesion and pre-PCI TIMI flow grade 1/0. Patients with high Lp(a) had a higher unadjusted odds of acute stent thrombosis (odds ratio [OR] 1.10 and 95% confidence interval [CI] 1.01-2.27), congestive heart failure (OR 1.24 and 95% CI 1.15-2.38) and composite in-hospital outcomes (OR 1.28 and 95% CI 1.18-2.42). After adjustment for covariates, patients with high Lp(a) still had a higher odds of congestive heart failure (OR 1.08 and 95% CI 1.01-1.78) and composite in-hospital outcomes (OR 1.12 and 95% CI 1.04-1.81).Conclusion: In ACS patients undergoing PCI, compared to those with low Lp(a), patients with high Lp(a) had more severe coronary artery lesion, higher risk of congestive heart failure and composite in-hospital outcomes.
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Affiliation(s)
| | | | | | - Hao Lu
- Department of Cardiology, Fuwai Hospital Chinese Academy Science of Medical Science, Shenzhen, Guangdong, China
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Increased cardiovascular risk associated with hyperlipoproteinemia (a) and the challenges of current and future therapeutic possibilities. Anatol J Cardiol 2020; 23:60-69. [PMID: 32011323 PMCID: PMC7040869 DOI: 10.14744/anatoljcardiol.2019.56068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Population, genetic, and clinical studies demonstrated a causative and continuous, from other plasma lipoproteins independent relationship between elevated plasma lipoprotein (a) [Lp(a)] concentration and the development of cardiovascular disease (CVD), mainly those related to athe-rosclerotic CVD, and calcific aortic stenosis. Currently, a strong international consensus is still lacking regarding the single value which would be commonly used to define hyperlipoproteinemia (a). Its prevalence in the general population is estimated to be in the range of 10%–35% in accordance with the most commonly used threshold levels (>30 or >50 mg/dL). Since elevated Lp(a) can be of special importance in patients with some genetic disorders, as well as in individuals with otherwise controlled major risk factors, the identification and establishment of the proper therapeutic interventions that would lower Lp(a) levels and lead to CVD risk reduction could be very important. The majority of the classical lipid-lowering agents (statins, ezetimibe, and fibrates), as well as nutraceuticals (CoQ10 and garlic), appear to have no significant effect on its plasma levels, whereas for the drugs with the demonstrated Lp(a)-lowering effects (aspirin, niacin, and estrogens), their clinical efficacy in reducing cardiovascular (CV) events has not been unequivocally proven yet. Both Lp(a) apheresis and proprotein convertase subtilisin/kexin type 9 inhibitors can reduce the plasma Lp(a) by approximately 20%–30% on average, in parallel with much larger reduction of low-density lipoprotein cholesterol (up to 70%), what puts us in a difficulty to conclude about the true contribution of lowered Lp(a) to the reduction of CV events. The most recent advancement in the field is the introduction of the novel apolipoprotein (a) [apo(a)] antisense oligonucleotide therapy targeting apo(a), which has already proven itself as being very effective in decreasing plasma Lp(a) (by even >90%), but should be further tested in clinical trials. The aim of this review was to present some of the most important accessible scientific data, as well as dilemmas related to the currently and potentially in the near future more widely available therapeutic options for the management of hyperlipoproteinemia (a).
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Lüscher TF. Frontiers in lipid research: lipoprotein(a), apolipoprotein C-III and E, and PCSK9 and inflammation. Eur Heart J 2020; 40:2741-2744. [PMID: 31505607 DOI: 10.1093/eurheartj/ehz633] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- Thomas F Lüscher
- Professor of Cardiology, Imperial College and Director of Research, Education & Development, Royal Brompton and Harefield Hospitals London, UK.,Professor and Chairman, Center for Molecular Cardiology, University of Zurich, Switzerland.,Editor-in-Chief, EHJ Editorial Office, Zurich Heart House, Hottingerstreet 14, Zurich, Switzerland
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Stiekema LCA, Stroes ESG, Verweij SL, Kassahun H, Chen L, Wasserman SM, Sabatine MS, Mani V, Fayad ZA. Persistent arterial wall inflammation in patients with elevated lipoprotein(a) despite strong low-density lipoprotein cholesterol reduction by proprotein convertase subtilisin/kexin type 9 antibody treatment. Eur Heart J 2020; 40:2775-2781. [PMID: 30561610 DOI: 10.1093/eurheartj/ehy862] [Citation(s) in RCA: 84] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 10/25/2018] [Accepted: 12/04/2018] [Indexed: 12/24/2022] Open
Abstract
AIMS Subjects with lipoprotein(a) [Lp(a)] elevation have increased arterial wall inflammation and cardiovascular risk. In patients at increased cardiovascular risk, arterial wall inflammation is reduced following lipid-lowering therapy by statin treatment or lipoprotein apheresis. However, it is unknown whether lipid-lowering treatment in elevated Lp(a) subjects alters arterial wall inflammation. We evaluated whether evolocumab, which lowers both low-density lipoprotein cholesterol (LDL-C) and Lp(a), attenuates arterial wall inflammation in patients with elevated Lp(a). METHODS AND RESULTS In this multicentre, randomized, double-blind, placebo-controlled study, 129 patients {median [interquartile range (IQR)]: age 60.0 [54.0-67.0] years, Lp(a) 200.0 [155.5-301.5] nmol/L [80.0 (62.5-121.0) mg/dL]; mean [standard deviation (SD)] LDL-C 3.7 [1.0] mmol/L [144.0 (39.7) mg/dL]; National Cholesterol Education Program high risk, 25.6%} were randomized to monthly subcutaneous evolocumab 420 mg or placebo. Compared with placebo, evolocumab reduced LDL-C by 60.7% [95% confidence interval (CI) 65.8-55.5] and Lp(a) by 13.9% (95% CI 19.3-8.5). Among evolocumab-treated patients, the Week 16 mean (SD) LDL-C level was 1.6 (0.7) mmol/L [60.1 (28.1) mg/dL], and the median (IQR) Lp(a) level was 188.0 (140.0-268.0) nmol/L [75.2 (56.0-107.2) mg/dL]. Arterial wall inflammation [most diseased segment target-to-background ratio (MDS TBR)] in the index vessel (left carotid, right carotid, or thoracic aorta) was assessed by 18F-fluoro-deoxyglucose positron-emission tomography/computed tomography. Week 16 index vessel MDS TBR was not significantly altered with evolocumab (-8.3%) vs. placebo (-5.3%) [treatment difference -3.0% (95% CI -7.4% to 1.4%); P = 0.18]. CONCLUSION Evolocumab treatment in patients with median baseline Lp(a) 200.0 nmol/L led to a large reduction in LDL-C and a small reduction in Lp(a), resulting in persistent elevated Lp(a) levels. The latter may have contributed to the unaltered arterial wall inflammation.
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Affiliation(s)
- Lotte C A Stiekema
- Department of Vascular Medicine, Amsterdam University Medical Center, University of Amsterdam, Meibergdreef 9, AZ Amsterdam, The Netherlands
| | - Erik S G Stroes
- Department of Vascular Medicine, Amsterdam University Medical Center, University of Amsterdam, Meibergdreef 9, AZ Amsterdam, The Netherlands
| | - Simone L Verweij
- Department of Vascular Medicine, Amsterdam University Medical Center, University of Amsterdam, Meibergdreef 9, AZ Amsterdam, The Netherlands
| | - Helina Kassahun
- Department of Clinical Development, Amgen Inc., One Amgen Center Drive Thousand Oaks, CA, USA
| | - Lisa Chen
- Department of Biostatistics, Amgen Inc., One Amgen Center Drive Thousand Oaks, CA, USA
| | - Scott M Wasserman
- Department of Clinical Development, Amgen Inc., One Amgen Center Drive Thousand Oaks, CA, USA
| | - Marc S Sabatine
- Division of Cardiovascular Medicine, TIMI Study Group, Brigham and Women's Hospital and Harvard Medical School, Fenwood Road, Boston, MA, USA
| | - Venkatesh Mani
- Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Pl, New York, NY, USA
| | - Zahi A Fayad
- Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Pl, New York, NY, USA
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Abstract
Abstract
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Affiliation(s)
- Angela Pirillo
- Center for the Study of Atherosclerosis, E. Bassini Hospital, Cinisello Balsamo, Milan, Italy
- IRCCS MultiMedica, Sesto S. Giovanni, Milan, Italy
| | - Alberico Luigi Catapano
- IRCCS MultiMedica, Sesto S. Giovanni, Milan, Italy
- Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy
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Welsh P, Welsh C, Celis-Morales CA, Brown R, Ho FK, Ferguson LD, Mark PB, Lewsey J, Gray SR, Lyall DM, Gill JMR, Pell JP, de Lemos JA, Willeit P, Sattar N. Lipoprotein(a) and cardiovascular disease: prediction, attributable risk fraction, and estimating benefits from novel interventions. Eur J Prev Cardiol 2020; 28:1991-2000. [PMID: 33624048 DOI: 10.1093/eurjpc/zwaa063] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 08/13/2020] [Accepted: 08/26/2020] [Indexed: 12/24/2022]
Abstract
AIMS To investigate the population attributable fraction due to elevated lipoprotein (a) (Lp(a)) and the utility of measuring Lp(a) in cardiovascular disease (CVD) risk prediction. METHODS AND RESULTS In 413 734 participants from UK Biobank, associations of serum Lp(a) with composite fatal/non-fatal CVD (n = 10 066 events), fatal CVD (n = 3247), coronary heart disease (CHD; n = 18 292), peripheral vascular disease (PVD; n = 2716), and aortic stenosis (n = 901) were compared using Cox models. Median Lp(a) was 19.7 nmol/L (interquartile interval 7.6-75.3 nmol/L). About 20.8% had Lp(a) values >100 nmol/L; 9.2% had values >175 nmol/L. After adjustment for classical risk factors, 1 SD increment in log Lp(a) was associated with a hazard ratio for fatal/non-fatal CVD of 1.12 [95% confidence interval (CI) 1.10-1.15]. Similar associations were observed with fatal CVD, CHD, PVD, and aortic stenosis. Adding Lp(a) to a prediction model containing traditional CVD risk factors in a primary prevention group improved the C-index by +0.0017 (95% CI 0.0008-0.0026). In the whole cohort, Lp(a) above 100 nmol/L was associated with a population attributable fraction (PAF) of 5.8% (95% CI 4.9-6.7%), and for Lp(a) above 175 nmol/L the PAF was 3.0% (2.4-3.6%). Assuming causality and an achieved Lp(a) reduction of 80%, an ongoing trial to lower Lp(a) in patients with CVD and Lp(a) above 175 nmol/L may reduce CVD risk by 20.0% and CHD by 24.4%. Similar benefits were also modelled in the whole cohort, regardless of baseline CVD. CONCLUSION Population screening for elevated Lp(a) may help to predict CVD and target Lp(a) lowering drugs, if such drugs prove efficacious, to those with markedly elevated levels.
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Affiliation(s)
- Paul Welsh
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, BHF Glasgow Cardiovascular Research Centre, 126 University Place, Glasgow G12 8TA, UK
| | - Claire Welsh
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle, UK
| | - Carlos A Celis-Morales
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, BHF Glasgow Cardiovascular Research Centre, 126 University Place, Glasgow G12 8TA, UK.,Institute of Health and Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow G12 8RZ, UK
| | - Rosemary Brown
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, BHF Glasgow Cardiovascular Research Centre, 126 University Place, Glasgow G12 8TA, UK
| | - Frederick K Ho
- Institute of Health and Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow G12 8RZ, UK
| | - Lyn D Ferguson
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, BHF Glasgow Cardiovascular Research Centre, 126 University Place, Glasgow G12 8TA, UK
| | - Patrick B Mark
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, BHF Glasgow Cardiovascular Research Centre, 126 University Place, Glasgow G12 8TA, UK
| | - James Lewsey
- Institute of Health and Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow G12 8RZ, UK
| | - Stuart R Gray
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, BHF Glasgow Cardiovascular Research Centre, 126 University Place, Glasgow G12 8TA, UK
| | - Donald M Lyall
- Institute of Health and Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow G12 8RZ, UK
| | - Jason M R Gill
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, BHF Glasgow Cardiovascular Research Centre, 126 University Place, Glasgow G12 8TA, UK
| | - Jill P Pell
- Institute of Health and Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow G12 8RZ, UK
| | - James A de Lemos
- Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, USA
| | - Peter Willeit
- Department of Neurology, Medical University of Innsbruck, Anichstraße 35, Innsbruck 6020, Austria.,Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, Worts Causeway, Cambridge CB1 8RN, UK
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, BHF Glasgow Cardiovascular Research Centre, 126 University Place, Glasgow G12 8TA, UK
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Afshar M, Rong J, Zhan Y, Chen HY, Engert JC, Sniderman AD, Larson MG, Vasan RS, Thanassoulis G. Risks of Incident Cardiovascular Disease Associated With Concomitant Elevations in Lipoprotein(a) and Low-Density Lipoprotein Cholesterol-The Framingham Heart Study. J Am Heart Assoc 2020; 9:e014711. [PMID: 32892691 PMCID: PMC7726982 DOI: 10.1161/jaha.119.014711] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 07/29/2020] [Indexed: 12/13/2022]
Abstract
Background Elevated lipoprotein(a) is a well-established risk factor for atherosclerotic vascular disease but is not measured in routine clinical care. Screening of high lipoprotein(a) in individuals with moderate elevations of low-density lipoprotein cholesterol (LDL-C) may identify individuals at high risk of cardiovascular disease. Methods and Results We examined 2606 Framingham Offspring participants (median age, 54 years; 45% men) prospectively with a median follow-up of 15 years (n=392 incident cardiovascular events). Individuals with higher (≥100 nmol/L) versus lower lipoprotein(a) were divided into groups based on LDL-C <135 mg/dL versus ≥135 mg/dL. In Cox models, after adjustment for known risk factors, high lipoprotein(a) (≥100 nmol/L) and LDL-C ≥135 mg/dL were each significant predictors of cardiovascular disease (LDL-C ≥135 mg/dL: hazard ratio [HR], 1.34; 95% CI, 1.09-1.64; P=0.006; high lipoprotein (a): HR, 1.31; 95% CI, 1.03-1.66; P=0.026). Across the groups of high/low lipoprotein (a) and LDL-C ≥135 mg/dL or <135 mg/dL, the absolute cardiovascular disease risks at 15 years were 22.6% (high lipoprotein(a)/LDL-C ≥135 mg/dL, n=248), 17.3% (low lipoprotein(a)/LDL-C ≥135 mg/dL, n=758), 12.7% (high lipoprotein(a)/LDL-C <135 mg/dL, n=275) and 11.5% (low lipoprotein(a)/LDL-C <135 mg/dL, n=1328, reference group). Among individuals with LDL-C ≥135 mg/dL, those with high lipoprotein(a) had a 43% higher risk (HR, 1.43; 95% CI, 1.05-1.97; P=0.02). Presence of high lipoprotein(a) with moderate LDL-C levels (135-159 mg/dL) yielded absolute risks equivalent to those with LDL-C ≥160 mg/dL (23.5%, 95% CI, 17.4%-31.3%; and 20.7%, 95% CI, 16.8%-25.3%, respectively). Conclusions Concomitant elevation of LDL-C ≥135 mg/dL and lipoprotein(a) ≥100 nmol/L is associated with a high absolute risk of incident cardiovascular disease. lipoprotein(a) measurement in individuals with moderate elevations in LDL-C, who do not otherwise meet criteria for statins, may identify individuals at high cardiovascular risk.
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Affiliation(s)
- Mehdi Afshar
- Division of CardiologyUniversity of TorontoTorontoCanada
| | - Jian Rong
- Department of NeurologyBoston University School of MedicineBostonMA
| | - Yang Zhan
- Department of MedicineMcGill UniversityMontrealCanada
- Preventive and Genomic CardiologyMcGill University Health Centre and Research InstituteMontrealCanada
- Division of CardiologyUniversity of SaskatchewanReginaCanada
| | - Hao Yu Chen
- Department of MedicineMcGill UniversityMontrealCanada
- Preventive and Genomic CardiologyMcGill University Health Centre and Research InstituteMontrealCanada
| | - James C. Engert
- Department of MedicineMcGill UniversityMontrealCanada
- Preventive and Genomic CardiologyMcGill University Health Centre and Research InstituteMontrealCanada
| | - Allan D. Sniderman
- Department of MedicineMcGill UniversityMontrealCanada
- Preventive and Genomic CardiologyMcGill University Health Centre and Research InstituteMontrealCanada
| | - Martin G. Larson
- NHLBI’s and Boston University’s Framingham Heart StudyBostonMA
- Department of BiostatisticsBoston University School of Public HealthBostonMA
| | - Ramachandran S. Vasan
- NHLBI’s and Boston University’s Framingham Heart StudyBostonMA
- Department of EpidemiologyBoston University School of Public HealthBostonMA
- Preventive Medicine and CardiologyBoston University School of MedicineBostonMA
| | - George Thanassoulis
- Department of MedicineMcGill UniversityMontrealCanada
- Preventive and Genomic CardiologyMcGill University Health Centre and Research InstituteMontrealCanada
- Department of Clinical EpidemiologyMcGill University Health CentreMontrealCanada
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Hu X, Yang X, Li X, Luo D, Zhou Y, Dong H. Lipoprotein (a) as a residual risk factor for atherosclerotic renal artery stenosis in hypertensive patients: a hospital-based cross-sectional study. Lipids Health Dis 2020; 19:173. [PMID: 32703301 PMCID: PMC7379345 DOI: 10.1186/s12944-020-01272-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 04/29/2020] [Indexed: 12/24/2022] Open
Abstract
Background Low-density lipoprotein cholesterol (LDL-c) has been proven to be a risk factor for atherosclerotic cardiovascular disease (CVD), while lipoprotein (a) (Lp(a)) is a residual risk factor for CVD, even though LDL-c is well controlled by statin use. Importantly, the role of Lp(a) in atherosclerotic renal artery stenosis (ARAS) is still unknown. Methods For this hospital-based cross-sectional study, patients who simultaneously underwent coronary and renal angiography were examined. ARAS was defined as a 50% reduction in the cross-sectional (two-dimensional plane) area of the renal artery. Data were collected and compared between ARAS and non-ARAS groups, including clinical history and metabolite profiles. Univariate analysis, three tertile LDL-c-based stratified analysis, and multivariate-adjusted logistic analysis were conducted, revealing a correlation between Lp(a) and ARAS. Results A total of 170 hypertensive patients were included in this study, 85 with ARAS and 85 with non-RAS. Baseline information indicated comparability between the two groups. In the univariate and multivariate analysis, common risk factors for atherosclerosis were not significantly different. Stratified analysis of LDL-c revealed a significant increase in the incidence of ARAS in patients who had high Lp(a) concentrations at low LDL-c levels (odds ratio (OR): 4.77, 95% confidence interval (CI): 1.04–21.79, P = 0.044). Further logistic analysis with adjusted covariates also confirmed the result, indicating that high Lp(a) levels were independently associated with ARAS (adjusted OR (aOR): 6.14, 95%CI: 1.03–36.47, P = 0.046). This relationship increased with increasing Lp(a) concentration based on a curve fitting graph. These results were not present in the low and intermediate LDL-c-level groups. Conclusion In hypertensive patients who present low LDL-c, high Lp(a) was significantly associated with atherosclerotic renal artery stenosis and thus is a residual risk factor.
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Affiliation(s)
- Xiangming Hu
- Department of Cardiology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, #96 Dongchuan Road, Guangzhou, 510080, Guangdong, China.,The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, Guangdong, China
| | - Xing Yang
- Department of Cardiology, Guangdong Provincial People's Hospital Zhuhai Hospital (Zhuhai Golden Bay Center Hospital), Zhuhai, 519040, Guangdong, China
| | - Xida Li
- Department of Cardiology, Guangdong Provincial People's Hospital Zhuhai Hospital (Zhuhai Golden Bay Center Hospital), Zhuhai, 519040, Guangdong, China
| | - Demou Luo
- Department of Cardiology, Vascular Center, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, #96 Dongchuan Road, Guangzhou, 510080, Guangdong, China
| | - Yingling Zhou
- Department of Cardiology, Vascular Center, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, #96 Dongchuan Road, Guangzhou, 510080, Guangdong, China.
| | - Haojian Dong
- Department of Cardiology, Vascular Center, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, #96 Dongchuan Road, Guangzhou, 510080, Guangdong, China.
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Shah NP, Pajidipati NJ, McGarrah RW, Navar AM, Vemulapalli S, Blazing MA, Shah SH, Hernandez AF, Patel MR. Lipoprotein (a): An Update on a Marker of Residual Risk and Associated Clinical Manifestations. Am J Cardiol 2020; 126:94-102. [PMID: 32336532 DOI: 10.1016/j.amjcard.2020.03.043] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Revised: 03/27/2020] [Accepted: 03/27/2020] [Indexed: 02/07/2023]
Abstract
Lipoprotein (a) [Lp(a)] is a low-density, cholesterol-containing lipoprotein that differs from other low-density lipoproteins due to the presence of apolipoprotein(a) bound to its surface apolipoprotein B100. Multiple epidemiologic studies, including Mendelian Randomization studies, have demonstrated that increasing Lp(a) levels are associated with increased risk of heart disease, including atherosclerotic cardiovascular disease and calcific aortic stenosis. The risk associated with elevations in Lp(a) appears to be independent of other lipid markers. While the current treatment options for elevated Lp(a) are limited, promising new therapies are under development, leading to renewed interest in Lp(a). This review provides an overview of the biology and epidemiology of Lp(a), available outcome studies, and insights into future therapies.
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67
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Lipoprotein(a) and Atherosclerotic Cardiovascular Disease: Current Understanding and Future Perspectives. Cardiovasc Drugs Ther 2020; 33:739-748. [PMID: 31655942 DOI: 10.1007/s10557-019-06906-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE To review current knowledge of elevated lipoprotein(a) [Lp(a)] levels in relation to atherosclerotic cardiovascular disease (ASCVD) and discuss their potential use as biomarkers and therapeutic approaches in clinical practice. METHODS We summarized the current understanding and recent advances in the structure, metabolism, atherogenic mechanisms, standardized laboratory measurement, recommended screening populations, and prognostic value of Lp(a), with a special focus on the current potential treatment approaches for hyperlipoprotein(a)emia in patients with ASCVD. RESULTS Lp(a) is composed of LDL-like particle and characteristic apolipoprotein(a) [apo(a)] connected by a disulfide bond. Substantial evidence shows that elevated plasma Lp(a) level is a heritable, independent, and possibly causal risk factor for ASCVD through its proatherogenic, proinflammatory, and potentially prothrombotic properties. Current guidelines recommend Lp(a) measurement for patients with an intermediate-high risk of ASCVD, familial hypercholesterolemia, a family history of early ASCVD or elevated Lp(a), and progressive ASCVD despite receiving optimal therapy. Traditional Lp(a)-lowering approaches such as niacin, PCSK9 inhibitors, mipomersen, lomitapide, and lipoprotein apheresis were associated with a non-specific and limited reduction of Lp(a), intolerable side effects, invasive procedure, and high expense. The phase 2 randomized controlled trial of antisense oligonucleotide against the apo(a) encoding gene LPA mRNA showed that IONIS-APO(a)-LRX could specifically reduce the level of Lp(a) by 90% with good tolerance, which may become a promising candidate for the prevention and treatment of ASCVD in the future. CONCLUSIONS It is reasonable to measure Lp(a) levels to reclassify ASCVD risk and manage individuals with elevated Lp(a) to further reduce the residual risk of ASCVD, especially with IONIS-APO(a)-LRX.
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Klingel R, Heigl F, Schettler V, Roeseler E, Grützmacher P, Hohenstein B, Vogt A, Fassbender C, Heibges A, Julius U. Lipoprotein(a) - Marker for cardiovascular risk and target for lipoprotein apheresis. ATHEROSCLEROSIS SUPP 2020; 40:17-22. [PMID: 31818445 DOI: 10.1016/j.atherosclerosissup.2019.08.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Lipoprotein(a) (Lp(a)) consists of an LDL particle whose apolipoprotein B (apoB) is covalently bound to apolipoprotein(a) (apo[a]). An increased Lp(a) concentration is a causal, independent risk factor for atherosclerotic cardiovascular disease (ASCVD) and a predictor of incident or recurrent cardiovascular events. Although Lp(a) was first described as early as 1963, only the more recent results of epidemiological, molecular, and genetic studies have led to this unequivocal conclusion. More than 20% of Western populations have elevated Lp(a) values. Lp(a) concentrations should be always part of the lipid profile when ASCVD risk is assessed. However, presence of other risk factors, laboratory findings, medical history and family history must be considered to conclude on its clinical relevance in an individual patient. Early or progressive ASCVD or a familial predisposition are key findings which can be associated with elevated Lp(a). The cholesterol portion contained in Lp(a) is also included in the various methods of LDL-C measurement. To assess proximity to the cardiovascular risk related target value for LDL-C, appropriate correction should be applied when high Lp(a) values are obtained to estimate the LDL-C that can actually be treated by lipid lowering drugs. Initial study data show that antisense oligonucleotides, which selectively decrease apolipoprotein(a), are promising as future treatment options. Currently, lipoprotein apheresis, which has a reimbursement guideline in Germany, is the therapy of choice for patients with Lp(a)-associated progressive ASCVD, with the aim of sustained prevention of further cardiovascular events.
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Affiliation(s)
- Reinhard Klingel
- Apheresis Research Institute, Cologne, Germany; First Department of Internal Medicine, University of Mainz, Mainz, Germany.
| | - Franz Heigl
- Medical Care Center Kempten-Allgäu, Kempten, Germany
| | | | - Eberhard Roeseler
- Center of Nephrology, Hypertension and Metabolic Diseases, Hannover, Germany
| | | | - Bernd Hohenstein
- Nephrological Center Villingen-Schwenningen, Villingen-Schwenningen, Germany; Department of Internal Medicine III, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Germany
| | - Anja Vogt
- Medizinische Klinik IV, Klinikum der Universität München, Germany
| | | | | | - Ulrich Julius
- Department of Internal Medicine III, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Germany
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Julius U, Tselmin S, Schatz U, Fischer S, Birkenfeld AL, Bornstein SR. Actual situation of lipoprotein apheresis in patients with elevated lipoprotein(a) levels. ATHEROSCLEROSIS SUPP 2020; 40:1-7. [PMID: 31818437 DOI: 10.1016/j.atherosclerosissup.2019.08.043] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
An elevation of lipoprotein(a) (Lp(a)) is an internationally recognized atherogenic risk factor, documented in epidemiological studies, in studies with Mendelian randomization and in genome-wide association studies (GWAS). At present, no drug is available to effectively reduce its concentration. In Germany, an elevation of Lp(a) associated with progressive cardiovascular diseases is officially recognized as an indication for a lipoprotein apheresis (LA). The number of patients who were treated with LA with this abnormality was steadily increasing in the years 2013-2016 - the official data are reported. In all new patients, who started to be treated at our LA center in 2017 (n = 20) the increased Lp(a) was a main indication for extracorporeal therapy, though some of them also showed clearly elevated LDL cholesterol (LDL-C) concentrations despite being treated with a maximal tolerated lipid-lowering drug therapy. A diabetes mellitus was seen in 5 patients. The higher was the Lp(a) level before the first LA session, the higher was the cardiovascular risk. Lp(a) concentrations measured before LA sessions were usually about 20% lower than those before the start of the LA therapy. Acutely, Lp(a) levels were reduced by about 70%. Following LA sessions the Lp(a) levels increased and in the majority reach pre-session concentrations after one week. Thus a weekly interval is best for the patients, but a few may need two sessions per week to stop the progress of atherosclerosis. The interval mean values were about 39% lower than previous levels. Several papers had been published showing a higher efficiency of LA therapy on the incidence of cardiovascular events in patients with high Lp(a) values when comparing with hypercholesterolemic patients with normal Lp(a) concentrations. Russian specific anti-Lp(a) columns positively affected coronary atherosclerosis. PCSK9 inhibitors reduce Lp(a) concentrations in many patients and in this way have a positive impact on cardiovascular outcomes. In the future, an antisense oligonucleotide against apolipoprotein(a) may be an alternative therapeutic option, provided a clear-cut reduction of cardiovascular events will be demonstrated.
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Affiliation(s)
- Ulrich Julius
- Lipidology and Center for Extracorporeal Treatment, Department of Internal Medicine III, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Germany, Fetscherstr. 74, 01307, Dresden, Germany.
| | - Sergey Tselmin
- Lipidology and Center for Extracorporeal Treatment, Department of Internal Medicine III, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Germany, Fetscherstr. 74, 01307, Dresden, Germany
| | - Ulrike Schatz
- Lipidology and Center for Extracorporeal Treatment, Department of Internal Medicine III, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Germany, Fetscherstr. 74, 01307, Dresden, Germany
| | - Sabine Fischer
- Lipidology and Center for Extracorporeal Treatment, Department of Internal Medicine III, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Germany, Fetscherstr. 74, 01307, Dresden, Germany
| | - Andreas L Birkenfeld
- Lipidology and Center for Extracorporeal Treatment, Department of Internal Medicine III, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Germany, Fetscherstr. 74, 01307, Dresden, Germany
| | - Stefan R Bornstein
- Lipidology and Center for Extracorporeal Treatment, Department of Internal Medicine III, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Germany, Fetscherstr. 74, 01307, Dresden, Germany
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What do we know about the role of lipoprotein(a) in atherogenesis 57 years after its discovery? Prog Cardiovasc Dis 2020; 63:219-227. [PMID: 32277995 DOI: 10.1016/j.pcad.2020.04.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 04/04/2020] [Indexed: 12/12/2022]
Abstract
Elevated circulating concentrations of lipoprotein(a) [Lp(a)] is strongly associated with increased risk of atherosclerotic cardiovascular disease (CVD) and degenerative aortic stenosis. This relationship was first observed in prospective observational studies, and the causal relationship was confirmed in genetic studies. Everybody should have their Lp(a) concentration measured once in their lifetime. CVD risk is elevated when Lp(a) concentrations are high i.e. > 50 mg/dL (≥100 mmol/L). Extremely high Lp(a) levels >180 mg/dL (≥430 mmol/L) are associated with CVD risk similar to that conferred by familial hypercholesterolemia. Elevated Lp(a) level was previously treated with niacin, which exerts a potent Lp(a)-lowering effect. However, niacin is currently not recommended because, despite the improvement in lipid profile, no improvements on clinical outcomes have been observed. Furthermore, niacin use has been associated with severe adverse effects. Post hoc analyses of clinical trials with proprotein convertase subtilisin/kexin type-9 (PCSK9) inhibitors have shown that these drugs exert clinical benefits by lowering Lp(a), independent of their potent reduction of low-density lipoprotein cholesterol (LDL-C). It is not yet known whether PCSK9 inhibitors will be of clinical use in patients with elevated Lp(a). Apheresis is a very effective approach to Lp(a) reduction, which reduces CVD risk but is invasive and time-consuming and is thus reserved for patients with very high Lp(a) levels and progressive CVD. Studies are ongoing on the practical application of genetic approaches to therapy, including antisense oligonucleotides against apolipoprotein(a) and small interfering RNA (siRNA) technology, to reduce the synthesis of Lp(a).
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Lee H, Park JB, Hwang IC, Yoon YE, Park HE, Choi SY, Kim YJ, Cho GY, Han K, Kim HK. Association of four lipid components with mortality, myocardial infarction, and stroke in statin-naïve young adults: A nationwide cohort study. Eur J Prev Cardiol 2020; 27:870-881. [DOI: 10.1177/2047487319898571] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Aims Dyslipidaemia is a modifiable cardiovascular risk factor with prognostic implications. Current strategies for lipid management in young adults are largely based on expert recommendations. We investigated the risks of death and cardiovascular disease in relation to each lipid component to establish evidence for primary prevention in young adults. Methods In this nationwide population-based cohort study, we analysed 5,688,055 statin-naïve subjects, aged 20–39 years, undergoing general health check-ups between 2009 and 2014. The endpoint was a composite of clinical events including death, myocardial infarction (MI), and stroke. We compared the incidence and risk of clinical events according to each lipid variable. Results During follow-up (median 7.1 years), clinical events occurred in 30,330 subjects (0.53%): 16,262 deaths (0.29%), 8578 MIs (0.15%), and 5967 strokes (0.10%). The risk of clinical events gradually increased with increasing total cholesterol (TC) and triglycerides and decreasing high-density lipoprotein cholesterol (HDL-C), largely driven by MI. Low-density lipoprotein cholesterol (LDL-C) had a J-shaped association with clinical events, showing the lowest risk for LDL-C of 84–101 mg/dL. Among lipid variables, triglycerides remained the sole independent predictor (adjusted hazard ratio, 1.20; p < 0.001) after adjusting for conventional risk factors. Conclusions For statin-naïve young adults, the risk of clinical events was proportional to lipid levels, positively with TC and triglycerides, negatively with HDL-C, and J-shaped with LDL-C. Triglycerides had an independent and the strongest association with the clinical events. Screening and intervention for abnormal lipid levels, particularly triglycerides, from an early age might be of clinical value.
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Affiliation(s)
- Heesun Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Healthcare System Gangnam Center, Seoul National University Hospital, Seoul, Korea
| | - Jun-Bean Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - In-Chang Hwang
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Cardiology, Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam, Gyeonggi, Korea
| | - Yeonyee E Yoon
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Cardiology, Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam, Gyeonggi, Korea
| | - Hyo Eun Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Healthcare System Gangnam Center, Seoul National University Hospital, Seoul, Korea
| | - Su-Yeon Choi
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Healthcare System Gangnam Center, Seoul National University Hospital, Seoul, Korea
| | - Yong-Jin Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Goo-Yeong Cho
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Cardiology, Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam, Gyeonggi, Korea
| | - Kyungdo Han
- Department of Medical Statistics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyung-Kwan Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
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Agarwala A, Shapiro MD. Emerging Strategies for the Management of Atherogenic Dyslipidaemia. Eur Cardiol 2020; 15:1-3. [PMID: 32180837 PMCID: PMC7066856 DOI: 10.15420/ecr.2019.16] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 10/29/2019] [Indexed: 12/24/2022] Open
Affiliation(s)
- Anandita Agarwala
- Division of Cardiology, Washington University School of Medicine, St Louis, MO, US
| | - Michael D Shapiro
- Center for Prevention of Cardiovascular Disease, Section on Cardiovascular Medicine, Wake Forest University Baptist Medical Center, Winston-Salem, NC, US
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Lüscher TF. Chronic coronary syndromes: expanding the spectrum and natural history of ischaemic heart disease. Eur Heart J 2020; 41:333-336. [PMID: 31942993 DOI: 10.1093/eurheartj/ehaa001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Thomas F Lüscher
- Professor of Cardiology, Imperial College and Director of Research, Education & Development, Royal Brompton and Harefield Hospitals London, UK.,Professor and Chairman, Center for Molecular Cardiology, University of Zurich, Switzerland.,Editor-in-Chief, EHJ Editorial Office, Zurich Heart House, Hottingerstreet 14, 8032 Zurich, Switzerland
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74
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Gencer B, Mach F. Potential of Lipoprotein(a)-Lowering Strategies in Treating Coronary Artery Disease. Drugs 2020; 80:229-239. [DOI: 10.1007/s40265-019-01243-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Madsen CM, Kamstrup PR, Langsted A, Varbo A, Nordestgaard BG. Lipoprotein(a)-Lowering by 50 mg/dL (105 nmol/L) May Be Needed to Reduce Cardiovascular Disease 20% in Secondary Prevention. Arterioscler Thromb Vasc Biol 2020; 40:255-266. [DOI: 10.1161/atvbaha.119.312951] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Objective:
High Lp(a) (lipoprotein[a]) cause cardiovascular disease (CVD) in a primary prevention setting; however, it is debated whether high Lp(a) lead to recurrent CVD events. We tested the latter hypothesis and estimated the Lp(a)-lowering needed for 5 years to reduce CVD events in a secondary prevention setting.
Approach and Results:
From the CGPS (Copenhagen General Population Study; 2003–2015) of 58 527 individuals with measurements of Lp(a), 2527 aged 20 to 79 with a history of CVD were studied. The primary end point was major adverse cardiovascular event (MACE). We also studied 1115 individuals with CVD from the CCHS (Copenhagen City Heart Study; 1991–1994) and the CIHDS (Copenhagen Ischemic Heart Disease Study; 1991–1993). During a median follow-up of 5 years (range, 0–13), 493 individuals (20%) experienced a MACE in the CGPS. MACE incidence rates per 1000 person-years were 29 (95% CI, 25–34) for individuals with Lp(a)<10 mg/dL, 35 (30–41) for 10 to 49 mg/dL, 42 (34–51) for 50 to 99 mg/dL, and 54 (42–70) for ≥100 mg/dL. Compared with individuals with Lp(a)<10 mg/dL (18 nmol/L), the multifactorially adjusted MACE incidence rate ratios were 1.28 (95% CI, 1.03–1.58) for 10 to 49 mg/dL (18–104 nmol/L), 1.44 (1.12–1.85) for 50 to 99 mg/dL (105–213 nmol/L), and 2.14 (1.57–2.92) for ≥100 mg/dL (214 nmol/L). Independent confirmation was obtained in individuals from the CCHS and CIHDS. To achieve 20% and 40% MACE risk reduction in secondary prevention, we estimated that plasma Lp(a) should be lowered by 50 mg/dL (95% CI, 27–138; 105 nmol/L [55–297]) and 99 mg/dL (95% CI, 54–273; 212 nmol/L [114–592]) for 5 years.
Conclusions:
High concentrations of Lp(a) are associated with high risk of recurrent CVD in individuals from the general population. This study suggests that Lp(a)-lowering by 50 mg/dL (105 nmol/L) short-term (ie, 5 years) may reduce CVD by 20% in a secondary prevention setting.
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Affiliation(s)
- Christian M. Madsen
- From the Department of Clinical Biochemistry (C.M.M., P.R.K., A.L., A.V., B.G.N.), Copenhagen University Hospital, Denmark
- The Copenhagen General Population Study, Herlev and Gentofte Hospital (C.M.M., P.R.K., A.L., A.V., B.G.N.), Copenhagen University Hospital, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Denmark (C.M.M., A.L., A.V., B.G.N.)
| | - Pia R. Kamstrup
- From the Department of Clinical Biochemistry (C.M.M., P.R.K., A.L., A.V., B.G.N.), Copenhagen University Hospital, Denmark
- The Copenhagen General Population Study, Herlev and Gentofte Hospital (C.M.M., P.R.K., A.L., A.V., B.G.N.), Copenhagen University Hospital, Denmark
| | - Anne Langsted
- From the Department of Clinical Biochemistry (C.M.M., P.R.K., A.L., A.V., B.G.N.), Copenhagen University Hospital, Denmark
- The Copenhagen General Population Study, Herlev and Gentofte Hospital (C.M.M., P.R.K., A.L., A.V., B.G.N.), Copenhagen University Hospital, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Denmark (C.M.M., A.L., A.V., B.G.N.)
| | - Anette Varbo
- From the Department of Clinical Biochemistry (C.M.M., P.R.K., A.L., A.V., B.G.N.), Copenhagen University Hospital, Denmark
- The Copenhagen General Population Study, Herlev and Gentofte Hospital (C.M.M., P.R.K., A.L., A.V., B.G.N.), Copenhagen University Hospital, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Denmark (C.M.M., A.L., A.V., B.G.N.)
| | - Børge G. Nordestgaard
- From the Department of Clinical Biochemistry (C.M.M., P.R.K., A.L., A.V., B.G.N.), Copenhagen University Hospital, Denmark
- The Copenhagen General Population Study, Herlev and Gentofte Hospital (C.M.M., P.R.K., A.L., A.V., B.G.N.), Copenhagen University Hospital, Denmark
- The Copenhagen City Heart Study, Frederiksberg Hospital (B.G.N.), Copenhagen University Hospital, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Denmark (C.M.M., A.L., A.V., B.G.N.)
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Julius U, Tselmin S, Schatz U, Fischer S, Bornstein SR. Lipoprotein(a) and proprotein convertase subtilisin/kexin type 9 inhibitors. Clin Res Cardiol Suppl 2019; 14:45-50. [PMID: 30838555 DOI: 10.1007/s11789-019-00099-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Lipoprotein(a) (Lp(a)) is an internationally accepted independent atherogenic risk factor. Details about its synthesis, many aspects of composition and clearance from the bloodstream are still unknown. LDL receptor (LDLR) (and probably other receptors) play a role in the elimination of Lp(a) particles. Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors increase the number of available LDLRs and in this way very effectively reduce the LDL cholesterol (LDL-C) concentrations. As shown in controlled studies using PCSK9 inhibitors, Lp(a) levels are decreased by 20 to 30%, though in some patients no effect was observed. So far, it has not been clarified whether this decrease is associated with an effect on the incidence of cardiovascular events (CVEs). In two recently published well-performed secondary prevention studies (FOURIER with evolocumab, ODYSSEY OUTCOMES with alirocumab) baseline Lp(a) levels were shown to have an impact on CVEs independently of baseline LDL-C concentrations. The rather modest PCSK9 inhibitor-induced decrease of Lp(a) was associated with a reduction of CVEs in both studies, even after adjusting (ODYSSEY OUTCOMES) for demographic variables (age, sex, race, region), baseline Lp(a), baseline LDL-C, change in LDL-C, and clinical variables (time from acute coronary syndrome, body mass index, diabetes, smoking history). The largest decrease of CVEs was seen in patients with relatively low concentrations of both LDL-C and Lp(a) (FOURIER). These findings will probably have an influence on the use of PCSK9 inhibitors in patients with high Lp(a) concentrations.
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Affiliation(s)
- U Julius
- Lipidology and Center for Extracorporeal Treatment, Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany.
| | - S Tselmin
- Lipidology and Center for Extracorporeal Treatment, Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - U Schatz
- Lipidology and Center for Extracorporeal Treatment, Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - S Fischer
- Lipidology and Center for Extracorporeal Treatment, Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - S R Bornstein
- Lipidology and Center for Extracorporeal Treatment, Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany
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77
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Ward NC, Kostner KM, Sullivan DR, Nestel P, Watts GF. Molecular, Population, and Clinical Aspects of Lipoprotein(a): A Bridge Too Far? J Clin Med 2019; 8:E2073. [PMID: 31783529 PMCID: PMC6947201 DOI: 10.3390/jcm8122073] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 11/15/2019] [Accepted: 11/15/2019] [Indexed: 12/16/2022] Open
Abstract
There is now significant evidence to support an independent causal role for lipoprotein(a) (Lp(a)) as a risk factor for atherosclerotic cardiovascular disease. Plasma Lp(a) concentrations are predominantly determined by genetic factors. However, research into Lp(a) has been hampered by incomplete understanding of its metabolism and proatherogeneic properties and by a lack of suitable animal models. Furthermore, a lack of standardized assays to measure Lp(a) and no universal consensus on optimal plasma levels remain significant obstacles. In addition, there are currently no approved specific therapies that target and lower elevated plasma Lp(a), although there are recent but limited clinical outcome data suggesting benefits of such reduction. Despite this, international guidelines now recognize elevated Lp(a) as a risk enhancing factor for risk reclassification. This review summarises the current literature on Lp(a), including its discovery and recognition as an atherosclerotic cardiovascular disease risk factor, attempts to standardise analytical measurement, interpopulation studies, and emerging therapies for lowering elevated Lp(a) levels.
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Affiliation(s)
- Natalie C. Ward
- School of Public Health, Curtin University, Perth 6102, Australia;
- School of Medicine, University of Western Australia, Perth 6009, Australia
| | - Karam M. Kostner
- Department of Cardiology, Mater Hospital, Brisbane 4104, Australia;
- School of Medicine University of Queensland, Brisbane 4072, Australia
| | - David R. Sullivan
- Medical School, The University of Sydney, Sydney 2006, Australia;
- Charles Perkins Centre, The University of Sydney, Sydney 2006, Australia
- Department of Biochemistry, Royal Prince Alfred Hospital, Sydney 2050, Australia
| | - Paul Nestel
- Baker Heart & Diabetes Institute, Melbourne 3004, Australia;
- Department of Cardiology, The Alfred Hospital, Melbourne 3004, Australia
| | - Gerald F. Watts
- School of Medicine, University of Western Australia, Perth 6009, Australia
- Lipid Disorders Clinic, Department of Cardiology, Royal Perth Hospital, Perth 6000, Australia
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Abstract
Loss-of-function variants in PCSK9 (proprotein convertase subtilisin-kexin type 9) are associated with lower lifetime risk of atherosclerotic cardiovascular disease) events. Confirmation of these genetic observations in large, prospective clinical trials in participants with atherosclerotic cardiovascular disease has provided guidance on risk stratification and enhanced our knowledge on hitherto unresolved and contentious issues concerning the efficacy and safety of markedly lowering LDL-C (low-density lipoprotein cholesterol). PCSK9 has a broad repertoire of molecular effects. Furthermore, clinical trials with PCSK9 inhibitors demonstrate that reductions in atherosclerotic cardiovascular disease events are more effective in patients with recent myocardial infarction, multiple myocardial infarctions, multivessel coronary artery disease, and lower extremity arterial disease. The potent LDL-C lowering efficacy of PCSK9 inhibitors provides the opportunity for more aggressive LDL-lowering strategies in high-risk patients with atherosclerotic cardiovascular disease and supports the notion that there is no lower limit for LDL-C. Aggressive LDL-C lowering with fully human PCSK9 monoclonal antibodies has been associated by a safety profile superior to that of other classes of LDL-lowering agents. These clinical trials provide evidence that LDL lowering with PCSK9 inhibitors is an effective therapy for lowering cardiovascular events in high-risk patients with LDL-C levels ≥70 mg/dL on maximally tolerated oral therapies, including statins and ezetimibe.
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Affiliation(s)
- Robert S Rosenson
- From the Zena and Michael A. Wiener Cardiovascular Institute and Marie-Josee and Henry R. Kravis Center for Cardiovascular Health, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY (R.S.R.)
| | - Robert A Hegele
- Department of Medicine and Robarts Research Institute, Schulich School of Medicine, Western University, London, Ontario, Canada
| | - Wolfgang Koenig
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany (W.K.).,DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany (W.K.).,Institute of Epidemiology and Biostatistics, University of Ulm, Germany (W.K.)
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79
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Engler RJM, Brede E, Villines T, Vernalis MN. Lipoprotein(a) Elevation: A New Diagnostic Code with Relevance to Service Members and Veterans. Fed Pract 2019; 36:S19-S31. [PMID: 31892786 PMCID: PMC6913584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Newly recognized as a clinical diagnosis, Lp(a) elevation is a major contributor to cardiovascular disease risk should be considered for patients with advanced premature atherosclerosis on imaging or a family history of premature cardiovascular disease, particularly when there are few traditional risk factors.
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Affiliation(s)
- Renata J M Engler
- is a Professor of Medicine and Pediatrics and is an Adjunct Assistant Professor of Medicine at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. is a Professor of Medicine in the Cardiology Division at the University of Virginia Health System in Charlottesville, Virginia. is a Protocol Developer; Renata Engler is a Consultant of Cardiovascular Immunology, Diagnostic Laboratory Immunology, Allergy-Immunizations, Integrative Medicine and Research; and Marina Vernalis is Medical Director, Integrative Cardiac Health Project, Cardiology; all at the Henry M. Jackson Foundation, in Bethesda
| | - Emily Brede
- is a Professor of Medicine and Pediatrics and is an Adjunct Assistant Professor of Medicine at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. is a Professor of Medicine in the Cardiology Division at the University of Virginia Health System in Charlottesville, Virginia. is a Protocol Developer; Renata Engler is a Consultant of Cardiovascular Immunology, Diagnostic Laboratory Immunology, Allergy-Immunizations, Integrative Medicine and Research; and Marina Vernalis is Medical Director, Integrative Cardiac Health Project, Cardiology; all at the Henry M. Jackson Foundation, in Bethesda
| | - Todd Villines
- is a Professor of Medicine and Pediatrics and is an Adjunct Assistant Professor of Medicine at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. is a Professor of Medicine in the Cardiology Division at the University of Virginia Health System in Charlottesville, Virginia. is a Protocol Developer; Renata Engler is a Consultant of Cardiovascular Immunology, Diagnostic Laboratory Immunology, Allergy-Immunizations, Integrative Medicine and Research; and Marina Vernalis is Medical Director, Integrative Cardiac Health Project, Cardiology; all at the Henry M. Jackson Foundation, in Bethesda
| | - Marina N Vernalis
- is a Professor of Medicine and Pediatrics and is an Adjunct Assistant Professor of Medicine at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. is a Professor of Medicine in the Cardiology Division at the University of Virginia Health System in Charlottesville, Virginia. is a Protocol Developer; Renata Engler is a Consultant of Cardiovascular Immunology, Diagnostic Laboratory Immunology, Allergy-Immunizations, Integrative Medicine and Research; and Marina Vernalis is Medical Director, Integrative Cardiac Health Project, Cardiology; all at the Henry M. Jackson Foundation, in Bethesda
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Lipoprotein apheresis efficacy, challenges and outcomes: A descriptive analysis from the UK Lipoprotein Apheresis Registry, 1989–2017. Atherosclerosis 2019; 290:44-51. [DOI: 10.1016/j.atherosclerosis.2019.09.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 09/10/2019] [Accepted: 09/12/2019] [Indexed: 01/01/2023]
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81
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Affiliation(s)
- Baris Gencer
- Cardiology Division, Department of Specialties in Medicine, Geneva University Hospitals, Rue Gabrielle-Perret Gentil 4, 1211 Geneva 14, Switzerland
| | - François Mach
- Cardiology Division, Department of Specialties in Medicine, Geneva University Hospitals, Rue Gabrielle-Perret Gentil 4, 1211 Geneva 14, Switzerland
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82
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Abstract
Abstract
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Affiliation(s)
- Angela Pirillo
- Center for the Study of Atherosclerosis, E. Bassini Hospital, Cinisello Balsamo, Milan, Italy
- IRCCS MultiMedica, Sesto S. Giovanni, Milan, Italy
| | - Alberico Luigi Catapano
- IRCCS MultiMedica, Sesto S. Giovanni, Milan, Italy
- Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy
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83
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Agarwala A, Liu J, Ballantyne CM, Virani SS. The Use of Risk Enhancing Factors to Personalize ASCVD Risk Assessment: Evidence and Recommendations from the 2018 AHA/ACC Multi-society Cholesterol Guidelines. CURRENT CARDIOVASCULAR RISK REPORTS 2019; 13:18. [PMID: 32864034 PMCID: PMC7451216 DOI: 10.1007/s12170-019-0616-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE OF REVIEW In 2018, the AHA/ACC multi-society Cholesterol Guidelines introduced the novel concept of risk-enhancing factors to be used as a supplement to the pooled cohort risk equations to personalize atherosclerotic cardiovascular disease risk assessment in primary prevention. In this review, we discuss the rationale and evidence behind each of the risk- enhancing factors to help clinicians perform a more personalized cardiovascular risk assessment. RECENT FINDINGS The risk-enhancing factors are high-risk features that may guide the use of lipid-lowering therapy particularly in intermediate and select borderline risk patients. For the purpose of this review, these factors are divided into 5 categories: (i) race and genetics, (ii) conditions specific to women (iii) lipid related risk, (iv) concurrent high-risk medical conditions, and (v) biomarkers. SUMMARY The addition of the risk-enhancing factors to the pooled cohort equations provides a more individualized and comprehensive approach to cardiovascular disease risk assessment.
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Affiliation(s)
- Anandita Agarwala
- Division of Cardiology, Washington University School of Medicine, 660 S. Euclid, Campus Box 8086, St. Louis, MO
| | - Jing Liu
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston TX
| | - Christie M. Ballantyne
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston TX
- Sections of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Salim S. Virani
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston TX
- Sections of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX
- Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX
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84
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Use of Lipoprotein(a) in clinical practice: A biomarker whose time has come. A scientific statement from the National Lipid Association. J Clin Lipidol 2019; 13:374-392. [DOI: 10.1016/j.jacl.2019.04.010] [Citation(s) in RCA: 202] [Impact Index Per Article: 40.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 04/26/2019] [Accepted: 04/26/2019] [Indexed: 12/24/2022]
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Abstract
Lipoprotein(a) (Lp(a)) is an independent cardiovascular risk factor playing a causal role for atherosclerotic cardiovascular disease (ASCVD). Early or progressive ASCVD or a familial predisposition are key findings which can be associated with Lp(a)-hyperlipoproteinemia (Lp(a)-HLP). The German guideline for the indication of lipoprotein apheresis in patients with Lp(a)-HLP has proved to be of value to identify patients at highest risk, using the composite of a Lp(a) threshold >60 mg/dl (>120 nmol/l) and clinical ASCVD progression despite effective LDL-C lowering therapy. In particular for such patients it appears to be plausible that Lp(a)-associated risk would increase cardiovascular mortality as the most important part of total mortality in Western populations. By the majority of existing investigations an association of Lp(a) concentration on total or cardiovascular mortality was demonstrated. However, inconsistency in the findings between studies exists without a clear trend for any study feature to explain this. Genetic homogeneity of the population, long-term follow-up, and clinically guided selection of patients might be important to further clarify the impact of Lp(a) concentration on progression of ASCVD, and finally total or cardiovascular mortality. LDL and Lp(a) particles exhibit a mutual effect modification on related ASCVD risk. Therefore, LDL-C levels and concomitant LDL-C lowering treatment must be considered in this context. Prospective evaluation is needed to document that specific Lp(a)-lowering additional to targeted LDL-C lowering will in fact reduce cardiovascular or total mortality.
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Affiliation(s)
- Reinhard Klingel
- Apheresis Research Institute, Stadtwaldguertel 77, 50935, Cologne, Germany.
- 1st Department of Internal Medicine, University of Mainz, Mainz, Germany.
| | - Andreas Heibges
- Apheresis Research Institute, Stadtwaldguertel 77, 50935, Cologne, Germany
| | - Cordula Fassbender
- Apheresis Research Institute, Stadtwaldguertel 77, 50935, Cologne, Germany
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86
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O’Donoghue ML, Fazio S, Giugliano RP, Stroes ES, Kanevsky E, Gouni-Berthold I, Im K, Lira Pineda A, Wasserman SM, Češka R, Ezhov MV, Jukema JW, Jensen HK, Tokgözoğlu SL, Mach F, Huber K, Sever PS, Keech AC, Pedersen TR, Sabatine MS. Lipoprotein(a), PCSK9 Inhibition, and Cardiovascular Risk. Circulation 2019; 139:1483-1492. [DOI: 10.1161/circulationaha.118.037184] [Citation(s) in RCA: 354] [Impact Index Per Article: 70.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Michelle L. O’Donoghue
- TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA (M.L.O., R.P.G., E.K., K.A.I., M.S.S.)
| | - Sergio Fazio
- Center for Preventive Cardiology, Knight Cardiovascular Institute, Oregon Health & Science University, Portland (S.F.)
| | - Robert P. Giugliano
- TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA (M.L.O., R.P.G., E.K., K.A.I., M.S.S.)
| | - Erik S.G. Stroes
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands (E.S.G.S.)
| | - Estella Kanevsky
- TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA (M.L.O., R.P.G., E.K., K.A.I., M.S.S.)
| | - Ioanna Gouni-Berthold
- Polyclinic for Endocrinology, Diabetes and Preventive Medicine, University of Cologne, Germany (I.G.-B.)
| | - KyungAh Im
- TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA (M.L.O., R.P.G., E.K., K.A.I., M.S.S.)
| | | | | | - Richard Češka
- Center for Preventive Cardiology, 3rd Internal Medicine Clinic, University General Hospital and Charles University 1st Medical Faculty, Prague, Czech Republic (R.C.)
| | - Marat V. Ezhov
- National Cardiology Research Center, Moscow, Russia (M.V.E.)
| | - J. Wouter Jukema
- Department of Cardiology, Leiden University Medical Center, The Netherlands (J.W.J.)
| | - Henrik K. Jensen
- Department of Cardiology, Aarhus University Hospital and Department of Clinical Medicine, Health, Aarhus University, Denmark (H.K.J.)
| | | | - François Mach
- Cardiology Division, University of Geneva, Switzerland (F.M.)
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital and Sigmund Freud University, Medical Faculty, Vienna, Austria (K.H.)
| | | | - Anthony C. Keech
- Sydney Medical School, National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Australia (A.C.K.)
| | - Terje R. Pedersen
- Oslo University Hospital, Ullevål and Medical Faculty, University of Oslo, Norway (T.R.P.)
| | - Marc S. Sabatine
- TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA (M.L.O., R.P.G., E.K., K.A.I., M.S.S.)
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87
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Affiliation(s)
- George Thanassoulis
- Preventive and Genomic Cardiology, McGill University Health Center and Research Institute, Montreal, Quebec, Canada
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88
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Reiner Ž. Can Lp(a) Lowering Against Background Statin Therapy Really Reduce Cardiovascular Risk? Curr Atheroscler Rep 2019; 21:14. [PMID: 30847681 DOI: 10.1007/s11883-019-0773-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW The association between elevated plasma levels of lipoprotein (a) [Lp(a)] and atherosclerotic cardiovascular disease (ASCVD) has been discussed for many years. Recent genetic findings have confirmed that elevated Lp(a) similar to elevated LDL-cholesterol (LDL-C) might be causally related to premature ASCVD. Lp(a) is relatively refractory to lifestyle interventions. The results of studies with statins and their possible effect on Lp(a) are conflicting. Specific Lp(a) apheresis is used as a treatment against background statin therapy and can decrease Lp(a). The purpose of this review is to discuss whether new drugs which decrease Lp(a) can prevent ASCVD and decrease ASCVD mortality when applied in addition to statins. RECENT FINDINGS Some new LDL-C-lowering drugs such as mipomersen and lomitapide decrease elevated Lp(a) in addition to statins but they have some unpleasant adverse effects. Recently, an antisense oligonucleotide against apo(a), AKCEA-APO(a)Rx, has been shown to selectively decrease Lp(a). The most recent advance in LDL-C lowering are PCSK9 inhibitors. Alirocumab and evolocumab do not only significantly reduce LDL-C on top of maximally tolerated statin therapy and prevent ASCVD events, but also further decrease Lp(a). There is no data to indicate whether mipomersen, lomitapide, or IONIS-APO(a)-LRx decrease ASCVD events and mortality. Conclusive evidence is still lacking as to whether the treatment with PCSK9 inhibitors against background statin therapy actually additionally reduces ASCVD risk due to the lowering of Lp(a) or simply due to lowering LDL-C to levels much lower than high-intensity statin treatment as monotherapy. Ongoing trials will probably provide an answer to these questions.
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Affiliation(s)
- Željko Reiner
- Department of Internal Medicine, University Hospital Centre Zagreb, School of Medicine, University of Zagreb, Kispaticeva 12, 10000, Zagreb, Croatia.
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89
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Nicholls SJ, Nelson AJ. The time for lipoprotein(a) based intervention has arrived: where will the light shine? J Thorac Dis 2019; 11:S433-S436. [PMID: 30997240 DOI: 10.21037/jtd.2018.11.54] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Stephen J Nicholls
- South Australian Health and Medical Research Institute, University of Adelaide, Adelaide, Australia.,Department of Medicine, Monash University, Melbourne, Australia
| | - Adam J Nelson
- South Australian Health and Medical Research Institute, University of Adelaide, Adelaide, Australia
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马 煜, 饶 甲, 龙 洁, 林 立, 刘 季, 郭 志. [Correlation of lipoprotein(a) with clinical stability and severity of coronary artery lesions in patients with coronary artery disease]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2019; 39:235-240. [PMID: 30890514 PMCID: PMC6765636 DOI: 10.12122/j.issn.1673-4254.2019.02.17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To analyze the correlation of lipoprotein(a) [Lp(a)] with the clinical stability and severity of coronary artery stenosis in patients with coronary artery disease (CAD). METHODS A total of 531 patients undergoing coronary angiography in Nanfang Hospital between January, 2013 and December, 2016 were enrolled in this study. At the cutoff Lp(a) concentration of 300 mg/L, the patients were divided into high Lp(a) group (n=191) and low Lp(a) group (n=340). In each group, the patients with an established diagnosis of CAD based on coronary angiography findings were further divided into stable angina pectoris (SAP) group and acute coronary syndrome (ACS) group. The correlation between the severity of coronary artery stenosis and Lp(a) was evaluated. RESULTS The patients in high and low Lp(a) groups showed no significant differences in age, gender, body mass index, smoking status, hypertension, or diabetes (P>0.05). Multivariate logistic regression analysis revealed that age, gender, and serum levels of low-density lipoprotein cholesterol (LDL-C) and Lp(a) were independent risk factors for CAD in these patients. A high Lp(a) level was associated with an increased risk of CAD (OR=2.443, 95%CI: 1.205-4.951, P=0.013). The patients with a high Lp(a) level were at a significantly higher risk of CAD than those with a low Lp(a) level irrespective of a low or high level of LDL-C (P=0.006 and 0.020). In the patients with CAD, the ACS group had a significantly higher Lp(a) level than the SAP group (P < 0.001); the proportion of the patients with high Gensini scores was significantly greater in high Lp(a) group than in low Lp(a) group (17.3% vs 5.6%, P=0.026), and a linear relationship was found between Lp(a) level and Gensini score (R=0.130, P=0.006). CONCLUSIONS Serum level of Lp(a) is an independent risk factor for CAD, and an increased Lp(a) is the residual risk for CAD. In patients with CAD, a high Lp(a) level is associated with the clinical instability and severity of coronary artery stenosis.
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Affiliation(s)
- 煜盛 马
- />南方医科大学南方医院心血管内科,广东 广州 510515Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - 甲环 饶
- />南方医科大学南方医院心血管内科,广东 广州 510515Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - 洁旎 龙
- />南方医科大学南方医院心血管内科,广东 广州 510515Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - 立龙 林
- />南方医科大学南方医院心血管内科,广东 广州 510515Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - 季晨 刘
- />南方医科大学南方医院心血管内科,广东 广州 510515Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - 志刚 郭
- />南方医科大学南方医院心血管内科,广东 广州 510515Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
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Spitthöver R, Röseler T, Julius U, Heigl F, Schettler VJJ, Kühn R, Leebmann J, Raabe A, Knittel M, Schürfeld C, Moesenthin M, Bernhardt WM, Röseler E, Ketteler M, Heibges A, Klingel R. Real-world study: Escalating targeted lipid-lowering treatment with PCSK9-inhibitors and lipoprotein apheresis. J Clin Apher 2019; 34:423-433. [DOI: 10.1002/jca.21695] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 02/12/2019] [Accepted: 02/13/2019] [Indexed: 11/11/2022]
Affiliation(s)
| | - Tilmann Röseler
- Center for Nephrology; Hypertension, and Metabolic Diseases; Hannover Germany
| | - Ulrich Julius
- 3 Medical Clinic; University Hospital at the Technische Universität; Dresden Germany
| | - Franz Heigl
- Medical Health and Care Center Kempten-Allgäu; Kempten Germany
| | | | - Ralf Kühn
- Clinic for Nephrology and Dialysis; Tangermünde Germany
| | - Josef Leebmann
- Interdisciplinary Apheresis Center at Passau General Hospital; Passau Germany
| | - Andrea Raabe
- Clinic for Nephrology; General Hospital; Coburg Germany
| | | | | | | | - Wanja M. Bernhardt
- Center for Nephrology; Hypertension, and Metabolic Diseases; Hannover Germany
| | - Eberhard Röseler
- Center for Nephrology; Hypertension, and Metabolic Diseases; Hannover Germany
| | | | | | - Reinhard Klingel
- Apheresis Research Institute; Cologne Germany
- First Department of Internal Medicine; University of Mainz; Mainz Germany
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92
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Lipoprotein(a) and secondary prevention of atherothrombotic events: A critical appraisal. J Clin Lipidol 2018; 12:1358-1366. [DOI: 10.1016/j.jacl.2018.08.012] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 08/16/2018] [Accepted: 08/29/2018] [Indexed: 12/24/2022]
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93
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The mediating role of Mediterranean diet on the association between Lp(a) levels and cardiovascular disease risk: A 10-year follow-up of the ATTICA study. Clin Biochem 2018; 60:33-37. [DOI: 10.1016/j.clinbiochem.2018.07.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 07/17/2018] [Accepted: 07/24/2018] [Indexed: 01/07/2023]
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