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Nordestgaard BG, Langsted A. Lipoprotein(a) and cardiovascular disease. Lancet 2024; 404:1255-1264. [PMID: 39278229 DOI: 10.1016/s0140-6736(24)01308-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Revised: 06/17/2024] [Accepted: 06/19/2024] [Indexed: 09/18/2024]
Abstract
One in five people are at high risk for atherosclerotic cardiovascular disease and aortic valve stenosis due to high lipoprotein(a). Lipoprotein(a) concentrations are lowest in people from east Asia, Europe, and southeast Asia, intermediate in people from south Asia, the Middle East, and Latin America, and highest in people from Africa. Concentrations are more than 90% genetically determined and 17% higher in post-menopausal women than in men. Individuals at a higher cardiovascular risk should have lipoprotein(a) concentrations measured once in their lifetime to inform those with high concentrations to adhere to a healthy lifestyle and receive medication to lower other cardiovascular risk factors. With no approved drugs to lower lipoprotein(a) concentrations, it is promising that at least five drugs in development lower concentrations by 65-98%, with three currently being tested in large cardiovascular endpoint trials. This Review covers historical perspectives, physiology and pathophysiology, genetic evidence of causality, epidemiology, role in familial hypercholesterolaemia and diabetes, management, screening, diagnosis, measurement, prevention, and future lipoprotein(a)-lowering drugs.
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Affiliation(s)
- Børge G Nordestgaard
- Department of Clinical Biochemistry, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
| | - Anne Langsted
- Department of Clinical Biochemistry, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Loh WJ, Chang X, Aw TC, Phua SK, Low AF, Chan MYY, Watts GF, Heng CK. Lipoprotein(a) as predictor of coronary artery disease and myocardial infarction in a multi-ethnic Asian population. Atherosclerosis 2021; 349:160-165. [PMID: 34887076 DOI: 10.1016/j.atherosclerosis.2021.11.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 11/15/2021] [Accepted: 11/17/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS The role of Lp(a) in multi-ethnic Asian populations with coronary artery disease (CAD) has not been well established. The aims of this study were (i) to investigate whether Lp(a) is a predictor of CAD, and (ii) amongst patients with CAD, to ascertain whether Lp(a) is a predictor of acute myocardial infarction (AMI) and severity of CAD. METHODS We compared three cardiovascular phenotypes from patients recruited at coronary angiography. CAD was defined as ≥50% coronary artery stenosis and subdivided into a group with AMI history (CAD+AMI+) and a group without (CAD+AMI-). Minimal CAD group (CAD-) was defined as normal or <30% coronary artery stenosis and no AMI. The severity of CAD was defined using the modified Gensini score. RESULTS We studied 2025 patients comprising 94.5% men and 61.4% of Chinese ethnicity. The median Lp(a) level was highest in CAD+AMI+, followed by CAD+AMI- and CAD- (26.2, 20.1, and 15.8 nmol/L respectively). Similarly, the frequency of patients with Lp(a) ≥120 nmol/L were in the same order (11.8%, 9.1% and 2.4%). Lp(a) levels were highest among Asian Indians, followed by Malays and Chinese patients (p < 0.001). Lp(a) levels and Lp(a) ≥120 nmol/L were significant predictors of CAD (Odds ratio (OR) = 1.12 per 10 nmol/L increment, p < 0.001, and OR = 5.41 p = 0.004 respectively). Among patients with CAD, higher Lp(a) levels were associated with increased AMI risk (OR = 1.02 per 10 nmol/L increment, p = 0.024). Lp(a) ≥120 nmol/L was positively associated with CAD severity (p = 0.020). CONCLUSIONS Plasma Lp(a) concentration is a positive predictor of CAD and AMI in a mostly male South East Asian population.
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Affiliation(s)
- Wann Jia Loh
- Department of Endocrinology, Changi General Hospital, 2 Simei Street 3, 529889, Singapore.
| | - Xuling Chang
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 12, 119228, Singapore; Khoo Teck Puat - National University Children's Medical Institute, National University Health System, 5 Lower Kent Ridge Road, 119074, Singapore
| | - Tar Choon Aw
- Department of Pathology, Changi General Hospital, 2 Simei Street 3, 529889, Singapore
| | - Soon Kieng Phua
- Department of Pathology, Changi General Hospital, 2 Simei Street 3, 529889, Singapore
| | - Adrian F Low
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, 117597, Singapore; National University Heart Centre, National University Health System, 119074, Singapore
| | - Mark Yan-Yee Chan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, 117597, Singapore; National University Heart Centre, National University Health System, 119074, Singapore
| | - Gerald F Watts
- School of Medicine, University of Western Australia, 35 Stirling Hwy, Crawley, WA, 6009, Australia; Department of Cardiology, Royal Perth Hospital, Western Australia, Victoria Square, Perth, WA, 6000, Australia
| | - Chew-Kiat Heng
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 12, 119228, Singapore; Khoo Teck Puat - National University Children's Medical Institute, National University Health System, 5 Lower Kent Ridge Road, 119074, Singapore
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Establishing age and sex dependent upper reference limits for the plasma lipoprotein (a) in a Chinese health check-up population and according to its relative risk of primary myocardial infarction. Clin Chim Acta 2018; 484:232-236. [PMID: 29883631 DOI: 10.1016/j.cca.2018.06.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 05/31/2018] [Accepted: 06/02/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND Though lipoprotein (a) (Lp (a)) has been considered as a risk factor for coronary artery disease, there is a lack of cutoff values of Lp (a) for Chinese Han ethnicity. METHODS We included 1 population for health check-ups. Lp (a) percentile distributions were analyzed and its cutoff for Chinese Han ethnicity was also proposed according to the its relative risk of myocardial infarction. RESULTS Lp (a) distributions differed between sexes, and were highly skewed towards low concentrations with a long tail towards the highest ones. The relative risks of elevated Lp (a) concentrations for myocardial infarction had an inflection in Chinese Han ethnic at the 8th decile, corresponding to 167 mg/l, where the risk was prone to be increased. In terms of Lp (a) median concentrations, per higher age quantile (5-y interval) was associated with a significant increase of 3.2 mg/l and females were on average 19.75 mg/l higher than males with a significant difference. CONCLUSIONS We proposed Lp (a) < 170 mg/l after rounding as cut-off values for Chinese Han ethnicity. Effects of age and sex on Lp (a) concentrations were also noted. Prospective validation of these cutoff values is critically important in Chinese Han ethnicity.
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Manocha A, Srivastava LM. Lipoprotein (a): a Unique Independent Risk Factor for Coronary Artery Disease. Indian J Clin Biochem 2015; 31:13-20. [PMID: 26855483 DOI: 10.1007/s12291-015-0483-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2015] [Accepted: 02/06/2015] [Indexed: 12/22/2022]
Abstract
The current epidemic affecting Indians is coronary artery disease (CAD), and is currently one of the most common causes of mortality and morbidity in developed and developing countries. The higher rate of CAD in Indians, as compared to people of other ethnic origin, may indicate a possible genetic susceptibility. Hence, Lp(a), an independent genetic risk marker for atherosclerosis and cardiovascular disease assumes great importance. Lp(a), an atherogenic lipoprotein, contains a cholesterol rich LDL particle, one molecule of apolipoprotein B-100 and a unique protein, apolipoprotein (a) which distinguishes it from LDL. Apo(a) is highly polymorphic and an inverse relationship between Lp(a) concentration and apo(a) isoform size has been observed. This is genetically controlled suggesting a functional diversity among the apo(a) isoforms. The LPA gene codes for apo(a) whose genetic heterogeneity is due to variations in its number of kringles. The exact pathogenic mechanism of Lp(a) is still not completely elucidated, but the structural homology of Lp(a) with LDL and plasmin is possibly responsible for its acting as a link between atherosclerosis and thrombosis. Upper limits of normal Lp(a) levels have not been defined for the Indian population. A cut off limit of 20 mg/dL has been suggested while for the Caucasian population it is 30 mg/dL. Though a variety of assays are available for its measurement, standardization of the analytical method is highly complicated as a majority of the methods are affected by the heterogeneity in apo(a) size. No therapeutic drug selectively targets Lp(a) but recently, new modifiers of apo(a) synthesis are being considered.
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Affiliation(s)
- Anjali Manocha
- Department of Biochemistry, Sir Ganga Ram Hospital, Rajender Nagar, New Delhi, 110060 India
| | - L M Srivastava
- Department of Biochemistry, Sir Ganga Ram Hospital, Rajender Nagar, New Delhi, 110060 India
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Rajasekhar D, Saibaba KSS, Srinivasa Rao PVLN, Latheef SAA, Subramanyam G. Lipoprotein (A): Better assessor of coronary heart disease risk in south Indian population. Indian J Clin Biochem 2012; 19:53-9. [PMID: 23105457 DOI: 10.1007/bf02894258] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
In an attempt to search for risk factors which can explain the increasing prevalence of coronary heart disease (CHD) in Indian population, we conducted a case-control study to assess the association of Lipoprotein (a)(Lp(a)) with CHD. One hundred and fifty one consecutive patients with clinical and angiographic evidence of CHD and forty-nine healthy controls were drawn for the study. Triglycerides, very low density cholesterol (VLDL-C), total cholesterol (total-C)/high density cholesterol (HDL-C) ratio, low density cholesterol (LDL-C)/HDL cholesterol ratio and Lp(a) were found to be higher in patients than controls. In female sex and in those with family history of CHD, higher total and LDL cholesterol levels were observed to be associated with higher Lp(a) levels. Lp(a) levels were also found to be higher in triple vessel disease than other vessel disease patients. Significant difference in Lp(a) levels were observed between normal coronaries vs. single and triple vessel disease(P<0.05) and also between single vs. double and triple vessel disease (P<0.01).Lp(a) levels correlated positively with vessel severity(P<0.005). Lp(a) levels >25 mg/dl were associated with coronary heart disease (Odds ratio 1.98 P<0.05 95% CI 0.007-1.18). Our findings suggest a cut-off level of 25mg/dl for determination of risk of CHD. Studies from different areas involving larger sample size are needed to confirm the findings of the present study.
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Affiliation(s)
- D Rajasekhar
- Department of Cardiology, Sri Venkatesware Institute of Medical Sciences, 517507 Tirupati, India
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Cardoso-Saldaña G, De La Peña-Díaz A, Zamora-González J, Gomez-Ortega R, Posadas-Romero C, Izaguirre-Avila R, Malvido-Miranda E, Morales-Anduaga ME, Angles-Cano E. Ethnicity and lipoprotein(a) polymorphism in Native Mexican populations. Ann Hum Biol 2006; 33:202-12. [PMID: 16684693 PMCID: PMC1940268 DOI: 10.1080/03014460500520006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Lp(a) is a lipoparticle of unknown function mainly present in primates and humans. It consists of a low-density lipoprotein and apo(a), a polymorphic glycoprotein. Apo(a) shares sequence homology and fibrin binding with plasminogen, inhibiting its fibrinolytic properties. Lp(a) is considered a link between atherosclerosis and thrombosis. Marked inter-ethnic differences in Lp(a) concentration related to the genetic polymorphism of apo(a) have been reported in several populations. AIM The study examined the structural and functional features of Lp(a) in three Native Mexican populations (Mayos, Mazahuas and Mayas) and in Mestizo subjects. METHODS We determined the plasma concentration of Lp(a) by immunonephelometry, apo(a) isoforms by Western blot, Lp(a) fibrin binding by immuno-enzymatic assay and short tandem repeat (STR) polymorphic marker genetic analysis by capillary electrophoresis. RESULTS Mestizos presented the less skewed distribution and the highest median Lp(a) concentration (13.25 mg dL(-1)) relative to Mazahuas (8.2 mg dL(-1)), Mayas (8.25 mg dL(-1)) and Mayos (6.5 mg dL(-1)). Phenotype distribution was different in Mayas and Mazahuas as compared with the Mestizo group. The higher Lp(a) fibrin-binding capacity was found in the Maya population. There was an inverse relationship between the size of apo(a) polymorphs and both Lp(a) levels and Lp(a) fibrin binding. CONCLUSION There is evidence of significative differences in Lp(a) plasma concentration and phenotype distribution in the Native Mexican and the Mestizo group.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Eduardo Angles-Cano
- Hémostase, bio-ingénierie et remodelage cardiovasculaires
INSERM : U698Université Denis Diderot - Paris VIIChu Xavier Bichat
46, Rue Henri Huchard
75877 PARIS CEDEX 18,FR
- * Correspondence should be adressed to: Eduardo Angles-Cano
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