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Thomas PE, Vedel-Krogh S, Kamstrup PR. High lipoprotein(a) is a risk factor for peripheral artery disease, abdominal aortic aneurysms, and major adverse limb events. Curr Opin Cardiol 2024; 39:511-519. [PMID: 39356276 DOI: 10.1097/hco.0000000000001168] [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] [Indexed: 10/03/2024]
Abstract
PURPOSE OF REVIEW To summarize evidence from recent studies of high lipoprotein(a) as a risk factor for peripheral artery disease (PAD), abdominal aortic aneurysms (AAA), and major adverse limb events (MALE). Additionally, provide clinicians with 10-year absolute risk charts enabling risk prediction of PAD and AAA by lipoprotein(a) levels and conventional risk factors. RECENT FINDINGS Numerous studies support high lipoprotein(a) as an independent risk factor for PAD, AAA, and MALE. The strongest evidence is from the Copenhagen General Population Study (CGPS) and the UK Biobank, two large general population-based cohorts. In the CGPS, a 50 mg/dl higher genetically determined lipoprotein(a) associated with hazard ratios of 1.39 (1.24-1.56) for PAD and 1.21 (1.01-1.44) for AAA. Corresponding hazard ratio in the UK Biobank were 1.38 (1.30-1.46) and 1.42 (1.28-1.59). In CGPS participants with levels at least 99th (≥143 mg/dl) vs, less than 50th percentile (≤9 mg/dl), hazard ratios were 2.99 (2.09-4.30) for PAD and 2.22 (1.21-4.07) for AAA, with a corresponding incidence rate ratio for MALE of 3.04 (1.55-5.98) in participants with PAD. SUMMARY Evidence from both observational and genetic studies support high lipoprotein(a) as a causal risk factor for PAD, AAA, and MALE, and highlight the potential of future lipoprotein(a)-lowering therapy to reduce the substantial morbidity and mortality associated with these diseases.
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Affiliation(s)
- Peter E Thomas
- Department of Clinical Biochemistry
- The Copenhagen General Population Study, Copenhagen University Hospital - Herlev and Gentofte
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Signe Vedel-Krogh
- Department of Clinical Biochemistry
- The Copenhagen General Population Study, Copenhagen University Hospital - Herlev and Gentofte
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Pia R Kamstrup
- Department of Clinical Biochemistry
- The Copenhagen General Population Study, Copenhagen University Hospital - Herlev and Gentofte
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
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2
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Dalla Vestra M, Grolla E, Autiero G, Presotto F. Peripheral artery disease risk factors: A focus on lipoprotein(a). Arch Cardiovasc Dis 2024:S1875-2136(24)00284-5. [PMID: 39227282 DOI: 10.1016/j.acvd.2024.07.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 07/04/2024] [Accepted: 07/14/2024] [Indexed: 09/05/2024]
Abstract
There is a well-established and strong link between high lipoprotein(a) concentration and coronary heart disease, but the evidence regarding peripheral artery disease and carotid atherosclerosis is not as conclusive. This review aims to summarize the relationships between lipoprotein(a), peripheral artery disease and carotid atherosclerosis, in order to try to understand the weight of lipoprotein(a) in determining the development, progression and any complications of atherosclerotic plaque at the carotid and peripheral artery level. There is currently no effective therapy to reduce lipoprotein(a) concentration, but understanding its significance as a vascular risk factor is the starting point to then explore (when effective therapies become available) if there is the possibility, even in patients with peripheral artery disease and carotid atherosclerosis, to achieve better control of the residual vascular risk that is ultimately induced by lipoprotein(a).
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Affiliation(s)
- Michele Dalla Vestra
- Department of Internal Medicine, Ospedale dell'Angelo, 30174 Mestre-Venezia, Italy.
| | - Elisabetta Grolla
- Department of Cardiology, Ospedale dell'Angelo, 30174 Mestre-Venezia, Italy
| | - Giuliana Autiero
- Department of Internal Medicine, Ospedale dell'Angelo, 30174 Mestre-Venezia, Italy
| | - Fabio Presotto
- Department of Internal Medicine, Ospedale dell'Angelo, 30174 Mestre-Venezia, Italy
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3
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Zhang N, Shi K, Ma S, Zhang X, Duan M, Zhang M, Liu Y, Gao T, Yang H, Ma X, Huang Y, Cheng Y, Qu H, Fan J, Yao Q, Zhan S. Correlation between lipoprotein(a) and recurrent ischemic events post-cerebral vascular stent implantation. J Stroke Cerebrovasc Dis 2024; 33:107882. [PMID: 39038628 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Revised: 07/16/2024] [Accepted: 07/19/2024] [Indexed: 07/24/2024] Open
Abstract
BACKGROUND AND AIM The association of Lipoprotein(a) (Lp[a]) with recurrent ischemic events in stented patients remains uncertain. So, this research aimed to investigate the impact of elevated Lp(a) levels on the occurrence of ischemic events in this specific patient population. METHODS Totally 553 patients who underwent intracranial or extracranial artery stent implantation were included. Baseline data were collected and postoperative ischemic outcomes were followed up. Cox regression analysis was used to investigate the association between Lp(a) and outcomes, while accounting for confounding factors. Finally, we established prediction models based on nomogram. RESULTS Of total 553 patients, a number of 107 (19.3%) experienced outcomes. These included 46 cases (25.4%) in group with elevated Lp(a) levels (>30 mg/dL) and 61 cases (16.4%) in non-elevated group (χ2=6.343, p=0.012). The group with elevated Lp(a) was 1.811 times more likely to experience ischemic events than the non-elevated group, each 1 mg/dL increase in Lp(a) resulted in a 1.008-fold increase in the recurrence rate of ischemic events. In addition, sex (male), previous history of coronary heart disease, decreased albumin, elevated very low density lipoprotein cholesterol and poorly controlled risk factors (including blood pressure and blood sugar) were also associated with a high risk of recurrent ischemic events after stent implantation. CONCLUSION Lp(a) elevation was a significant risk factor for ischemic events in symptomatic patients who underwent intracranial or extracranial artery stenting.
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Affiliation(s)
- Nan Zhang
- Department of Neurology, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710004, China
| | - Kaili Shi
- Department of Neurology, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710004, China
| | - Shuyin Ma
- Department of Neurology, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710004, China
| | - Xiaodong Zhang
- Department of Neurology, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710004, China
| | - Minyu Duan
- Department of Neurology, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710004, China
| | - Mengyuan Zhang
- Department of Neurology, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710004, China
| | - Yixin Liu
- Department of Neurology, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710004, China
| | - Tiantian Gao
- Department of Neurology, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710004, China
| | - Han Yang
- Department of Neurology, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710004, China
| | - Xiaodong Ma
- Department of Neurology, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710004, China
| | - Yizhou Huang
- Department of Neurology, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710004, China
| | - Yuxuan Cheng
- Department of Neurology, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710004, China
| | - Huiyang Qu
- Department of Neurology, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710004, China
| | - Jiaxin Fan
- Department of Neurology, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710004, China
| | - Qingling Yao
- Department of Neurology, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710004, China
| | - Shuqin Zhan
- Department of Neurology, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710004, China.
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4
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Bellomo TR, Liu Y, Gilliland TC, Miksenas H, Haidermota S, Wong M, Hu X, Cristino JR, Browne A, Plutzky J, Tsimikas S, Januzzi JL, Natarajan P. Associations between lipoprotein(a), oxidized phospholipids, and extracoronary vascular disease. J Lipid Res 2024; 65:100585. [PMID: 38942114 PMCID: PMC11298641 DOI: 10.1016/j.jlr.2024.100585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 06/20/2024] [Accepted: 06/21/2024] [Indexed: 06/30/2024] Open
Abstract
The roles of lipoprotein(a) [Lp(a)] and related oxidized phospholipids (OxPLs) in the development and progression of coronary disease is known, but their influence on extracoronary vascular disease is not well-established. We sought to evaluate associations between Lp(a), OxPL apolipoprotein B (OxPL-apoB), and apolipoprotein(a) (OxPL-apo(a)) with angiographic extracoronary vascular disease and incident major adverse limb events (MALEs). Four hundred forty-six participants who underwent coronary and/or peripheral angiography were followed up for a median of 3.7 years. Lp(a) and OxPLs were measured before angiography. Elevated Lp(a) was defined as ≥150 nmol/L. Elevated OxPL-apoB and OxPL-apo(a) were defined as greater than or equal to the 75th percentile (OxPL-apoB ≥8.2 nmol/L and OxPL-apo(a) ≥35.8 nmol/L, respectively). Elevated Lp(a) had a stronger association with the presence of extracoronary vascular disease compared to OxPLs and was minimally improved with the addition of OxPLs in multivariable models. Compared to participants with normal Lp(a) and OxPL concentrations, participants with elevated Lp(a) levels were twice as likely to experience a MALE (odds ratio: 2.14, 95% confidence interval: 1.03, 4.44), and the strength of the association as well as the C statistic of 0.82 was largely unchanged with the addition of OxPL-apoB and OxPL-apo(a). Elevated Lp(a) and OxPLs are risk factors for progression and complications of extracoronary vascular disease. However, the addition of OxPLs to Lp(a) does not provide additional information about risk of extracoronary vascular disease. Therefore, Lp(a) alone captures the risk profile of Lp(a), OxPL-apoB, and OxPL-apo(a) in the development and progression of atherosclerotic plaque in peripheral arteries.
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Affiliation(s)
- Tiffany R Bellomo
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Yuxi Liu
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Thomas C Gilliland
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of Harvard and MIT, Cambridge, MA, USA
| | - Hannah Miksenas
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Sara Haidermota
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Megan Wong
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Xingdi Hu
- Novartis Pharmaceuticals Corporation, Novartis, East Hanover, NJ, USA
| | | | - Auris Browne
- Novartis Pharmaceuticals Corporation, Novartis, East Hanover, NJ, USA
| | - Jorge Plutzky
- Division of Cardiology, Brigham and Women's Hospital, Boston, Harvard Medical School, Boston, MA, USA
| | - Sotirios Tsimikas
- Sulpizio Cardiovascular Center, University of California San Diego, La Jolla, CA, USA
| | - James L Januzzi
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Cardiology Division, Baim Institute for Clinical Research, Boston, MA, USA
| | - Pradeep Natarajan
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of Harvard and MIT, Cambridge, MA, USA.
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5
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Pavlatos N, Kalra DK. The Role of Lipoprotein(a) in Peripheral Artery Disease. Biomedicines 2024; 12:1229. [PMID: 38927436 PMCID: PMC11200468 DOI: 10.3390/biomedicines12061229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2024] [Revised: 05/25/2024] [Accepted: 05/29/2024] [Indexed: 06/28/2024] Open
Abstract
Lipoprotein(a) is a low-density-lipoprotein-like particle that consists of apolipoprotein(a) bound to apolipoprotein(b). It has emerged as an established causal risk factor for atherosclerotic cardiovascular disease, stroke, and aortic valve stenosis through multifactorial pathogenic mechanisms that include inflammation, atherogenesis, and thrombosis. Despite an estimated 20% of the global population having elevated lipoprotein(a) levels, testing remains underutilized due to poor awareness and a historical lack of effective and safe therapies. Although lipoprotein(a) has a strong association with coronary artery disease and cerebrovascular disease, its relationship with peripheral artery disease is less well established. In this article, we review the epidemiology, biology, and pathogenesis of lipoprotein(a) as it relates to peripheral artery disease. We also discuss emerging treatment options to help mitigate major adverse cardiac and limb events in this population.
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Affiliation(s)
- Nicholas Pavlatos
- Department of Internal Medicine, University of Louisville School of Medicine, Louisville, KY 40202, USA;
| | - Dinesh K. Kalra
- Division of Cardiology, University of Louisville School of Medicine, Louisville, KY 40202, USA
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6
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Kaur G, Abdelrahman K, Berman AN, Biery DW, Shiyovich A, Huck D, Garshick M, Blankstein R, Weber B. Lipoprotein(a): Emerging insights and therapeutics. Am J Prev Cardiol 2024; 18:100641. [PMID: 38646022 PMCID: PMC11033089 DOI: 10.1016/j.ajpc.2024.100641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 02/08/2024] [Accepted: 02/24/2024] [Indexed: 04/23/2024] Open
Abstract
The strong association between lipoprotein (a) [Lp(a)] and atherosclerotic cardiovascular disease has led to considerations of Lp(a) being a potential target for mitigating residual cardiovascular risk. While approximately 20 % of the population has an Lp(a) level greater than 50 mg/dL, there are no currently available pharmacological lipid-lowering therapies that have demonstrated substantial reduction in Lp(a). Novel therapies to lower Lp(a) include antisense oligonucleotides and small-interfering ribonucleic acid molecules and have shown promising results in phase 2 trials. Phase 3 trials are currently underway and will test the causal relationship between Lp(a) and ASCVD and whether lowering Lp(a) reduces cardiovascular outcomes. In this review, we summarize emerging insights related to Lp(a)'s role as a risk-enhancing factor for ASCVD, association with calcific aortic stenosis, effects of existing therapies on Lp(a) levels, and variations amongst patient populations. The evolving therapeutic landscape of emerging therapeutics is further discussed.
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Affiliation(s)
- Gurleen Kaur
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Adam N. Berman
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - David W. Biery
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Albert Einstein College of Medicine, New York, NY, USA
| | - Arthur Shiyovich
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Daniel Huck
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Ron Blankstein
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Brittany Weber
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
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7
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Sosnowska B, Stepinska J, Mitkowski P, Bielecka-Dabrowa A, Bobrowska B, Budzianowski J, Burchardt P, Chlebus K, Dobrowolski P, Gasior M, Jankowski P, Kubica J, Mickiewicz A, Mysliwiec M, Osadnik T, Prejbisz A, Rajtar-Salwa R, Wita K, Witkowski A, Gil R, Banach M. Recommendations of the Experts of the Polish Cardiac Society (PCS) and the Polish Lipid Association (PoLA) on the diagnosis and management of elevated lipoprotein(a) levels. Arch Med Sci 2024; 20:8-27. [PMID: 38414479 PMCID: PMC10895977 DOI: 10.5114/aoms/183522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 01/31/2024] [Indexed: 02/29/2024] Open
Abstract
Lipoprotein(a) [Lp(a)] is made up of a low-density lipoprotein (LDL) particle and a specific apolipoprotein(a). The blood concentration of Lp(a) is approximately 90% genetically determined, and the main genetic factor determining Lp(a) levels is the size of the apo(a) isoform, which is determined by the number of KIV2 domain repeats. The size of the apo(a) isoform is inversely proportional to the blood concentration of Lp(a). Lp(a) is a strong and independent cardiovascular risk factor. Elevated Lp(a) levels ≥ 50 mg/dl (≥ 125 nmol/l) are estimated to occur in more than 1.5 billion people worldwide. However, determination of Lp(a) levels is performed far too rarely, including Poland, where, in fact, it is only since the 2021 guidelines of the Polish Lipid Association (PoLA) and five other scientific societies that Lp(a) measurements have begun to be performed. Determination of Lp(a) concentrations is not easy due to, among other things, the different sizes of the apo(a) isoforms; however, the currently available certified tests make it possible to distinguish between people with low and high cardiovascular risk with a high degree of precision. In 2022, the first guidelines for the management of patients with elevated lipoprotein(a) levels were published by the European Atherosclerosis Society (EAS) and the American Heart Association (AHA). The first Polish guidelines are the result of the work of experts from the two scientific societies and their aim is to provide clear, practical recommendations for the determination and management of elevated Lp(a) levels.
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Affiliation(s)
- Bożena Sosnowska
- Department of Preventive Cardiology and Lipidology, Medical University of Lodz (MUL), Lodz, Poland
| | | | - Przemyslaw Mitkowski
- 1 Department of Cardiology, Poznan University of Medical Sciences, Poznan, Poland
| | - Agata Bielecka-Dabrowa
- Department of Preventive Cardiology and Lipidology, Medical University of Lodz (MUL), Lodz, Poland
- Department of Cardiology and Adult Congenital Defects, Polish Mother's Memorial Hospital Research Institute (PMMHRI), Lodz, Poland
| | - Beata Bobrowska
- Department of Clinical Cardiology and Cardiovascular Interventions, University Hospital in Krakow, Krakow, Poland
| | - Jan Budzianowski
- Department of Interventional Cardiology and Cardiac Surgery, University of Zielona Gora, Collegium Medicum, Zielona Gora, Poland
- Multidisciplinary Hospital, Nowa Sol, Poland
| | - Pawel Burchardt
- Department of Cardiology, J. Strus Hospital, Poznan, Poland
- Department of Hypertension, Angiology and Internal Medicine, Poznan University of Medical Sciences, Poznan, Poland
| | - Krzysztof Chlebus
- National Center for Familial Hypercholesterolemia, 1 Chair and Department of Cardiology, Medical University of Gdansk, Gdansk, Poland
| | - Piotr Dobrowolski
- Department of Epidemiology, Cardiovascular Disease Prevention and Health Promotion, National Institute of Cardiology, Warsaw, Poland
| | - Mariusz Gasior
- 3 Department of Cardiology, Silesian Centre for Heart Diseases, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Zabrze, Poland
| | - Piotr Jankowski
- Department of Internal Medicine and Geriatric Cardiology, Medical Centre for Postgraduate Education, Warsaw, Poland
| | - Jacek Kubica
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Agnieszka Mickiewicz
- Lipoprotein Apheresis Laboratory, 1 Department of Cardiology, Medical University of Gdansk, Gdansk, Poland
| | - Malgorzata Mysliwiec
- Department of Paediatrics, Diabetology and Endocrinology, Medical University of Gdansk, Gdansk, Poland
| | - Tadeusz Osadnik
- Department of Pharmacology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Aleksander Prejbisz
- Department of Epidemiology, Cardiovascular Disease Prevention and Health Promotion, National Institute of Cardiology, Warsaw, Poland
| | - Renata Rajtar-Salwa
- Department of Clinical Cardiology and Cardiovascular Interventions, University Hospital in Krakow, Krakow, Poland
| | - Kristian Wita
- 1 Department of Cardiology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Adam Witkowski
- Department of Interventional Cardiology and Angiology, National Institute of Cardiology, Warsaw, Poland
| | - Robert Gil
- Department of Cardiology, National Medical Institute of the Ministry of Internal Affairs and Administration, Warsaw, Poland
| | - Maciej Banach
- Department of Preventive Cardiology and Lipidology, Medical University of Lodz (MUL), Lodz, Poland
- Department of Cardiology and Adult Congenital Defects, Polish Mother's Memorial Hospital Research Institute (PMMHRI), Lodz, Poland
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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8
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Mukherjee D, Nissen SE. Lipoprotein (a) as a Biomarker for Cardiovascular Diseases and Potential New Therapies to Mitigate Risk. Curr Vasc Pharmacol 2024; 22:171-179. [PMID: 38141196 DOI: 10.2174/0115701611267835231210054909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 11/16/2023] [Accepted: 11/16/2023] [Indexed: 12/25/2023]
Abstract
BACKGROUND Lipoprotein (a) [Lp(a)] is a molecule that induces inflammation of the blood vessels, atherogenesis, valvular calcification, and thrombosis. METHODS We review the available evidence that suggests that high Lp(a) levels are associated with a persisting risk for atherosclerotic cardiovascular diseases despite optimization of established risk factors, including low-density lipoprotein cholesterol (LDL-C) levels. OBSERVATIONS Approximately a quarter of the world population have Lp(a) levels of >50 mg/dL (125 nmol/L), a level associated with elevated cardiovascular risk. Lifestyle modification, statins, and ezetimibe do not effectively lower Lp(a) levels, while proprotein convertase subtilisin/kexin type 9 (PCSK-9) inhibitors and niacin only lower Lp(a) levels modestly. We describe clinical studies suggesting that gene silencing therapeutics, such as small interfering RNA (siRNA) and antisense oligonucleotide targeting Lp(a), offer a targeted approach with the potential for safe and robust Lp(a)- lowering with only a few doses (3-4) per year. Prospective randomized phase 3 studies are ongoing to validate safety, effectiveness in improving hard clinical outcomes, and tolerability to assess these therapies. CONCLUSION Several emerging treatments with robust Lp(a)-lowering effects may significantly lower atherosclerotic cardiovascular risk.
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Affiliation(s)
- Debabrata Mukherjee
- Department of Internal Medicine, Texas Tech University Health Sciences Center at El Paso, Texas, USA
| | - Steven E Nissen
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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9
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Loh WJ, Pang J, Chakraborty A, Ward NC, Chan DC, Hooper AJ, Bell DA, Burnett JR, Martin AC, Watts GF. Cascade testing of children and adolescents for elevated Lp(a) in pedigrees with familial hypercholesterolaemia. J Clin Lipidol 2024; 18:e33-e37. [PMID: 38040538 DOI: 10.1016/j.jacl.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 11/09/2023] [Indexed: 12/03/2023]
Abstract
Elevated plasma lipoprotein(a) [Lp(a)] is a common, inherited condition independently causing cardiovascular disease. Recent expert recommendations suggest opportunistically testing for elevated Lp(a) during cascade testing for familial hypercholesterolaemia (FH). We investigated the effectiveness of detecting elevated Lp(a) in 103 children and adolescents who were first-degree relatives of 66 adult index FH cases as part of an established FH cascade screening program. The yield of detection of elevated Lp(a) using a threshold of ≥30 mg/dL in children and adolescents was assessed. Cascade testing from FH index cases with elevated Lp(a) ≥50 mg/dL identified 1 case of Lp(a) ≥30 mg/dL for every 2 children or adolescents tested. In contrast, opportunistic screening from index cases with FH but normal Lp(a) levels demonstrated 1 case of Lp(a) ≥30 mg/dL for every 7.5 children or adolescents tested (p < 0.001). In conclusion, cascade testing for elevated Lp(a) from index cases with FH and elevated Lp(a) is effective in identifying new cases of elevated Lp(a).
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Affiliation(s)
- Wann Jia Loh
- School of Medicine, University of Western Australia, Perth, Australia (Drs Loh, Pang, Chakraborty, Chan, Hooper, Bell, Burnett, Watts); Department of Endocrinology, Changi General Hospital, Singapore (Dr Loh); Duke-NUS Medical School, Singapore (Dr Loh).
| | - Jing Pang
- School of Medicine, University of Western Australia, Perth, Australia (Drs Loh, Pang, Chakraborty, Chan, Hooper, Bell, Burnett, Watts)
| | - Anindita Chakraborty
- School of Medicine, University of Western Australia, Perth, Australia (Drs Loh, Pang, Chakraborty, Chan, Hooper, Bell, Burnett, Watts)
| | - Natalie C Ward
- Dobney Hypertension Centre, Medical School, University of Western Australia (Dr Ward)
| | - Dick C Chan
- School of Medicine, University of Western Australia, Perth, Australia (Drs Loh, Pang, Chakraborty, Chan, Hooper, Bell, Burnett, Watts)
| | - Amanda J Hooper
- School of Medicine, University of Western Australia, Perth, Australia (Drs Loh, Pang, Chakraborty, Chan, Hooper, Bell, Burnett, Watts); Department of Biochemistry, Royal Perth Hospital and Fiona Stanley Hospital Network, Pathwest Laboratory Medicine, Perth, Australia (Drs Hooper, Bell)
| | - Damon A Bell
- School of Medicine, University of Western Australia, Perth, Australia (Drs Loh, Pang, Chakraborty, Chan, Hooper, Bell, Burnett, Watts); Department of Biochemistry, Royal Perth Hospital and Fiona Stanley Hospital Network, Pathwest Laboratory Medicine, Perth, Australia (Drs Hooper, Bell); Department of Cardiology and Internal Medicine, Royal Perth Hospital, Perth, Australia (Drs Bell, Burnett, Watts)
| | - John R Burnett
- School of Medicine, University of Western Australia, Perth, Australia (Drs Loh, Pang, Chakraborty, Chan, Hooper, Bell, Burnett, Watts); Department of Cardiology and Internal Medicine, Royal Perth Hospital, Perth, Australia (Drs Bell, Burnett, Watts)
| | - Andrew C Martin
- School of Paediatrics and Child Health, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Western Australia, Australia (Dr Martin); Department of General Paediatrics, Perth Children's Hospital, Perth, Western Australia, Australia (Dr Martin)
| | - Gerald F Watts
- School of Medicine, University of Western Australia, Perth, Australia (Drs Loh, Pang, Chakraborty, Chan, Hooper, Bell, Burnett, Watts); Department of Cardiology and Internal Medicine, Royal Perth Hospital, Perth, Australia (Drs Bell, Burnett, Watts)
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10
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Orfanos P, Fonseca AF, Hu X, Gautam R, Montgomery G, Studer R, Kaur J, Saxena N, Kaushik N. Burden of elevated lipoprotein(a) among patients with atherosclerotic cardiovascular disease: Evidence from a systematic literature review and feasibility assessment of meta-analysis. PLoS One 2023; 18:e0294250. [PMID: 37983217 PMCID: PMC10659166 DOI: 10.1371/journal.pone.0294250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 10/17/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND Elevated lipoprotein(a) [Lp(a)] level is an independent genetic risk factor that increases the risk of atherosclerotic cardiovascular disease (ASCVD) by 2-4 fold. We aimed to report the burden of clinically relevant elevated Lp(a) in secondary prevention ASCVD population as the evaluation of such evidence is lacking. METHODS A systematic literature review (SLR) was conducted using Embase®, MEDLINE®, and MEDLINE® In-Process databases to identify studies reporting burden of elevated Lp(a) levels from January 1, 2010, to March 28, 2022. Full-text, English-language studies including ≥500 participants with ≥1 Lp(a) assessment were included. RESULTS Sixty-one studies reported clinical burden of elevated Lp(a). Of these, 25 observational studies and one clinical trial reported clinical burden of clinically relevant elevated Lp(a) levels. Major clinical outcomes included major adverse cardiovascular event (MACE; n = 20), myocardial infarction (MI; n = 11), revascularization (n = 10), stroke (n = 10), cardiovascular (CV) mortality (n = 9), and all-cause mortality (n = 10). Elevated Lp(a) levels significantly increased the risk of MACE (n = 15) and revascularization (n = 8), while they demonstrated a trend for positive association with remaining CV outcomes. Meta-analysis was not feasible for included studies due to heterogeneity in Lp(a) thresholds, outcome definitions, and patient characteristics. Three studies reported humanistic burden. Patients with elevated Lp(a) levels had higher odds of manifesting cognitive impairment (odds ratio [OR] [95% confidence interval; CI]: 1.62 [1.11-2.37]) and disability related to stroke (OR [95% CI]:1.46 [1.23-1.72)]) (n = 2). Elevated Lp(a) levels negatively correlated with health-related quality of life (R = -0.166, p = 0.014) (n = 1). A single study reported no association between elevated Lp(a) levels and economic burden. CONCLUSIONS This SLR demonstrated a significant association of elevated Lp(a) levels with major CV outcomes and increased humanistic burden in secondary prevention ASCVD population. These results reinforce the need to quantify and manage Lp(a) for CV risk reduction and to perform further studies to characterize the economic burden.
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Affiliation(s)
| | | | - Xingdi Hu
- Value and Access, Novartis Pharmaceutical Corporation, East Hanover, New Jersey, United States of America
| | - Raju Gautam
- Value and Access, Novartis Healthcare Pvt. Ltd., Hyderabad, India
| | | | - Rachel Studer
- Value and Access, Novartis Pharma AG, Basel, Switzerland
| | - Japinder Kaur
- Value and Access, Novartis Healthcare Pvt. Ltd., Hyderabad, India
| | - Nehul Saxena
- Value and Access, Novartis Healthcare Pvt. Ltd., Hyderabad, India
| | - Nitin Kaushik
- Value and Access, Novartis Healthcare Pvt. Ltd., Hyderabad, India
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11
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Steg PG, Szarek M, Valgimigli M, Islam S, Zeiher AM, Bhatt DL, Bittner VA, Chiang CE, Diaz R, Goodman SG, Gotcheva N, Harrington RA, Jukema JW, Kim HS, Kim SH, Morais J, Pordy R, Scemama M, White HD, Schwartz GG. Lipoprotein(a) and the Effect of Alirocumab on Revascularization After Acute Coronary Syndrome. Can J Cardiol 2023; 39:1315-1324. [PMID: 37116789 DOI: 10.1016/j.cjca.2023.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 04/14/2023] [Accepted: 04/20/2023] [Indexed: 04/30/2023] Open
Abstract
BACKGROUND Many patients require revascularization after index acute coronary syndrome (ACS). Lipoprotein(a) is thought to play a pathogenic role in atherothrombosis. In ODYSSEY OUTCOMES, alirocumab reduced major adverse cardiovascular events after ACS, with greater reduction among those with higher lipoprotein(a) levels. We explored whether risk of revascularization after ACS was modified by the level of lipoprotein(a) and treatment with alirocumab or placebo. METHODS In ODYSSEY OUTCOMES alirocumab was compared with placebo in 18,924 patients with ACS and elevated atherogenic lipoprotein levels despite optimized statin treatment. In this post hoc analysis, treatment effects are summarized using competing risks proportional hazard models. RESULTS A total of 1559 (8.2%) patients had coronary, 204 (1.1%) had limb, and 40 (0.2%) had carotid revascularization. Alirocumab reduced coronary revascularization (2.8 vs 3.2 events per 100 patient-years; hazard ratio [HR], 0.88 [95% confidence interval (CI), 0.80-0.97]; P = 0.01) and any revascularization (3.2 vs 3.7 events per 100 patient-years; HR, 0.85 [95% CI, 0.78-0.94]; P = 0.001). Baseline lipoprotein(a) quartile was directly associated with risk of coronary or any revascularization in the placebo arm and inversely related to treatment HRs (all P for trend < 0.01). Alirocumab produced the greatest reduction of coronary revascularization in patients with baseline lipoprotein(a) in the top quartile (≥ 59.6 mg/dL; HR, 0.69 [95% CI, 0.57-0.84]), but no apparent reduction in the bottom quartile (HR, 1.00 [95% CI, 0.82-1.22]). Findings were similar for the effect of alirocumab on any revascularization. CONCLUSIONS Alirocumab reduced revascularization rates after ACS. The risk of revascularization and reduction in that risk with alirocumab were greatest in patients with elevated lipoprotein(a) at baseline.
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Affiliation(s)
- P Gabriel Steg
- Department of Cardiology, Université Paris-Cité, INSERM-UMR1148, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, French Alliance for Cardiovascular Trials, and Institut Universitaire de France, Paris, France.
| | - Michael Szarek
- CPC Clinical Research and Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado, USA; State University of New York, Downstate Health Sciences University, Brooklyn, New York, USA
| | - Marco Valgimigli
- Division of Cardiology, Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano, Switzerland; Department of Cardiology,University of Bern, Bern, Switzerland
| | - Shahidul Islam
- Division of Health Services Research, NYU Long Island School of Medicine, Mineola, New York, USA
| | - Andreas M Zeiher
- Department of Medicine III, Goethe University, Frankfurt am Main, Germany
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, New York, New York, USA
| | - Vera A Bittner
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Chern-En Chiang
- General Clinical Research Center, Division of Cardiology, Taipei Veterans General Hospital and National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Rafael Diaz
- Estudios Cardiológicos Latinoamérica, Instituto Cardiovascular de Rosario, Rosario, Argentina
| | - Shaun G Goodman
- Department of Medicine, Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada; Division of Cardiology, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Nina Gotcheva
- Department of Cardiology, MHAT "National Cardiology Hospital" EAD, Sofia, Bulgaria
| | - Robert A Harrington
- Stanford Center for Clinical Research, Department of Medicine, Stanford University, Stanford, California, USA
| | - J Wouter Jukema
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands; Netherlands Heart Institute, Utrecht, The Netherlands
| | - Hyo-Soo Kim
- Departmentof Cardiology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sang-Hyun Kim
- Division of Cardiology, SMG Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Joao Morais
- Division of Cardiology, Leiria Hospital Center, Leiria, Portugal; ciTechCare, Polytechnic of Leiria, Leiria, Portugal
| | - Robert Pordy
- Regeneron Pharmaceuticals Inc, Tarrytown, New York, USA
| | | | - Harvey D White
- Green Lane Cardiovascular Services, Auckland City Hospital and Auckland University, Auckland, New Zealand
| | - Gregory G Schwartz
- Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado, USA
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12
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Vinci P, Di Girolamo FG, Panizon E, Tosoni LM, Cerrato C, Pellicori F, Altamura N, Pirulli A, Zaccari M, Biasinutto C, Roni C, Fiotti N, Schincariol P, Mangogna A, Biolo G. Lipoprotein(a) as a Risk Factor for Cardiovascular Diseases: Pathophysiology and Treatment Perspectives. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6721. [PMID: 37754581 PMCID: PMC10531345 DOI: 10.3390/ijerph20186721] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 07/31/2023] [Accepted: 08/09/2023] [Indexed: 09/28/2023]
Abstract
Cardiovascular disease (CVD) is still a leading cause of morbidity and mortality, despite all the progress achieved as regards to both prevention and treatment. Having high levels of lipoprotein(a) [Lp(a)] is a risk factor for cardiovascular disease that operates independently. It can increase the risk of developing cardiovascular disease even when LDL cholesterol (LDL-C) levels are within the recommended range, which is referred to as residual cardiovascular risk. Lp(a) is an LDL-like particle present in human plasma, in which a large plasminogen-like glycoprotein, apolipoprotein(a) [Apo(a)], is covalently bound to Apo B100 via one disulfide bridge. Apo(a) contains one plasminogen-like kringle V structure, a variable number of plasminogen-like kringle IV structures (types 1-10), and one inactive protease region. There is a large inter-individual variation of plasma concentrations of Lp(a), mainly ascribable to genetic variants in the Lp(a) gene: in the general po-pulation, Lp(a) levels can range from <1 mg/dL to >1000 mg/dL. Concentrations also vary between different ethnicities. Lp(a) has been established as one of the risk factors that play an important role in the development of atherosclerotic plaque. Indeed, high concentrations of Lp(a) have been related to a greater risk of ischemic CVD, aortic valve stenosis, and heart failure. The threshold value has been set at 50 mg/dL, but the risk may increase already at levels above 30 mg/dL. Although there is a well-established and strong link between high Lp(a) levels and coronary as well as cerebrovascular disease, the evidence regarding incident peripheral arterial disease and carotid atherosclerosis is not as conclusive. Because lifestyle changes and standard lipid-lowering treatments, such as statins, niacin, and cholesteryl ester transfer protein inhibitors, are not highly effective in reducing Lp(a) levels, there is increased interest in developing new drugs that can address this issue. PCSK9 inhibitors seem to be capable of reducing Lp(a) levels by 25-30%. Mipomersen decreases Lp(a) levels by 25-40%, but its use is burdened with important side effects. At the current time, the most effective and tolerated treatment for patients with a high Lp(a) plasma level is apheresis, while antisense oligonucleotides, small interfering RNAs, and microRNAs, which reduce Lp(a) levels by targeting RNA molecules and regulating gene expression as well as protein production levels, are the most widely explored and promising perspectives. The aim of this review is to provide an update on the current state of the art with regard to Lp(a) pathophysiological mechanisms, focusing on the most effective strategies for lowering Lp(a), including new emerging alternative therapies. The purpose of this manuscript is to improve the management of hyperlipoproteinemia(a) in order to achieve better control of the residual cardiovascular risk, which remains unacceptably high.
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Affiliation(s)
- Pierandrea Vinci
- Clinica Medica, Cattinara Hospital, Department of Medical Surgical and Health Science, University of Trieste, 34149 Trieste, Italy; (F.G.D.G.); (E.P.); (L.M.T.); (C.C.); (F.P.); (N.A.); (A.P.); (M.Z.); (N.F.); (G.B.)
| | - Filippo Giorgio Di Girolamo
- Clinica Medica, Cattinara Hospital, Department of Medical Surgical and Health Science, University of Trieste, 34149 Trieste, Italy; (F.G.D.G.); (E.P.); (L.M.T.); (C.C.); (F.P.); (N.A.); (A.P.); (M.Z.); (N.F.); (G.B.)
- SC Assistenza Farmaceutica, Cattinara Hospital, Azienda Sanitaria Universitaria Integrata di Trieste, 34149 Trieste, Italy; (C.B.); (C.R.); (P.S.)
| | - Emiliano Panizon
- Clinica Medica, Cattinara Hospital, Department of Medical Surgical and Health Science, University of Trieste, 34149 Trieste, Italy; (F.G.D.G.); (E.P.); (L.M.T.); (C.C.); (F.P.); (N.A.); (A.P.); (M.Z.); (N.F.); (G.B.)
| | - Letizia Maria Tosoni
- Clinica Medica, Cattinara Hospital, Department of Medical Surgical and Health Science, University of Trieste, 34149 Trieste, Italy; (F.G.D.G.); (E.P.); (L.M.T.); (C.C.); (F.P.); (N.A.); (A.P.); (M.Z.); (N.F.); (G.B.)
| | - Carla Cerrato
- Clinica Medica, Cattinara Hospital, Department of Medical Surgical and Health Science, University of Trieste, 34149 Trieste, Italy; (F.G.D.G.); (E.P.); (L.M.T.); (C.C.); (F.P.); (N.A.); (A.P.); (M.Z.); (N.F.); (G.B.)
| | - Federica Pellicori
- Clinica Medica, Cattinara Hospital, Department of Medical Surgical and Health Science, University of Trieste, 34149 Trieste, Italy; (F.G.D.G.); (E.P.); (L.M.T.); (C.C.); (F.P.); (N.A.); (A.P.); (M.Z.); (N.F.); (G.B.)
| | - Nicola Altamura
- Clinica Medica, Cattinara Hospital, Department of Medical Surgical and Health Science, University of Trieste, 34149 Trieste, Italy; (F.G.D.G.); (E.P.); (L.M.T.); (C.C.); (F.P.); (N.A.); (A.P.); (M.Z.); (N.F.); (G.B.)
| | - Alessia Pirulli
- Clinica Medica, Cattinara Hospital, Department of Medical Surgical and Health Science, University of Trieste, 34149 Trieste, Italy; (F.G.D.G.); (E.P.); (L.M.T.); (C.C.); (F.P.); (N.A.); (A.P.); (M.Z.); (N.F.); (G.B.)
| | - Michele Zaccari
- Clinica Medica, Cattinara Hospital, Department of Medical Surgical and Health Science, University of Trieste, 34149 Trieste, Italy; (F.G.D.G.); (E.P.); (L.M.T.); (C.C.); (F.P.); (N.A.); (A.P.); (M.Z.); (N.F.); (G.B.)
| | - Chiara Biasinutto
- SC Assistenza Farmaceutica, Cattinara Hospital, Azienda Sanitaria Universitaria Integrata di Trieste, 34149 Trieste, Italy; (C.B.); (C.R.); (P.S.)
| | - Chiara Roni
- SC Assistenza Farmaceutica, Cattinara Hospital, Azienda Sanitaria Universitaria Integrata di Trieste, 34149 Trieste, Italy; (C.B.); (C.R.); (P.S.)
| | - Nicola Fiotti
- Clinica Medica, Cattinara Hospital, Department of Medical Surgical and Health Science, University of Trieste, 34149 Trieste, Italy; (F.G.D.G.); (E.P.); (L.M.T.); (C.C.); (F.P.); (N.A.); (A.P.); (M.Z.); (N.F.); (G.B.)
| | - Paolo Schincariol
- SC Assistenza Farmaceutica, Cattinara Hospital, Azienda Sanitaria Universitaria Integrata di Trieste, 34149 Trieste, Italy; (C.B.); (C.R.); (P.S.)
| | - Alessandro Mangogna
- Institute for Maternal and Child Health, I.R.C.C.S “Burlo Garofolo”, 34137 Trieste, Italy;
| | - Gianni Biolo
- Clinica Medica, Cattinara Hospital, Department of Medical Surgical and Health Science, University of Trieste, 34149 Trieste, Italy; (F.G.D.G.); (E.P.); (L.M.T.); (C.C.); (F.P.); (N.A.); (A.P.); (M.Z.); (N.F.); (G.B.)
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13
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Farina JM, Pereyra M, Mahmoud AK, Chao CJ, Barry T, Halli Demeter SM, Ayoub C, Arsanjani R. Current Management and Future Perspectives in the Treatment of Lp(a) with a Focus on the Prevention of Cardiovascular Diseases. Pharmaceuticals (Basel) 2023; 16:919. [PMID: 37513831 PMCID: PMC10385436 DOI: 10.3390/ph16070919] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 06/14/2023] [Accepted: 06/21/2023] [Indexed: 07/30/2023] Open
Abstract
Lipoprotein(a) [Lp(a)] is a lipid molecule with atherogenic, inflammatory, thrombotic, and antifibrinolytic effects, whose concentrations are predominantly genetically determined. The association between Lp(a) and cardiovascular diseases (CVDs) has been well-established in numerous studies, and the ability to measure Lp(a) levels is widely available in the community. As such, there has been increasing interest in Lp(a) as a therapeutic target for the prevention of CVD. The impact of the currently available lipid-modifying agents on Lp(a) is modest and heterogeneous, except for the monoclonal antibody proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i), which demonstrated a significant reduction in Lp(a) levels. However, the absolute reduction in Lp(a) to significantly decrease CVD outcomes has not been definitely established, and the magnitude of the effect of PCSK9i seems insufficient to directly reduce the Lp(a)-related CVD risk. Therefore, emerging therapies are being developed that specifically aim to lower Lp(a) levels and the risk of CVD, including RNA interference (RNAi) agents, which have the capacity for temporary and reversible downregulation of gene expression. This review article aims to summarize the effects of Lp(a) on CVD and to evaluate the available evidence on established and emerging therapies targeting Lp(a) levels, focusing on the potential reduction of CVD risk attributable to Lp(a) concentrations.
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Affiliation(s)
- Juan M Farina
- Department of Cardiovascular Medicine, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054, USA
| | - Milagros Pereyra
- Department of Cardiovascular Medicine, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054, USA
| | - Ahmed K Mahmoud
- Department of Cardiovascular Medicine, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054, USA
| | - Chieh-Ju Chao
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Timothy Barry
- Department of Cardiovascular Medicine, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054, USA
| | - Susan M Halli Demeter
- Department of Cardiovascular Medicine, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054, USA
| | - Chadi Ayoub
- Department of Cardiovascular Medicine, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054, USA
| | - Reza Arsanjani
- Department of Cardiovascular Medicine, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054, USA
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14
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Amiri M, Raeisi-Dehkordi H, Verkaar AJCF, Wu Y, van Westing AC, Berk KA, Bramer WM, Aune D, Voortman T. Circulating lipoprotein (a) and all-cause and cause-specific mortality: a systematic review and dose-response meta-analysis. Eur J Epidemiol 2023; 38:485-499. [PMID: 36708412 PMCID: PMC10164031 DOI: 10.1007/s10654-022-00956-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 12/16/2022] [Indexed: 01/29/2023]
Abstract
AIMS To investigate the association between circulating lipoprotein(a) (Lp(a)) and risk of all-cause and cause-specific mortality in the general population and in patients with chronic diseases, and to elucidate the dose-response relations. METHODS AND RESULTS We searched literature to find prospective studies reporting adjusted risk estimates on the association of Lp(a) and mortality outcomes. Forty-three publications, reporting on 75 studies (957,253 participants), were included. The hazard ratios (HRs) and 95% confidence intervals (95%CI ) for the top versus bottom tertile of Lp(a) levels and risk of all-cause mortality were 1.09 (95%CI: 1.01-1.18, I2: 75.34%, n = 19) in the general population and 1.18 (95%CI: 1.04-1.34, I2: 52.5%, n = 12) in patients with cardiovascular diseases (CVD). The HRs for CVD mortality were 1.33 (95%CI: 1.11-1.58, I2: 82.8%, n = 31) in the general population, 1.25 (95%CI: 1.10-1.43, I2: 54.3%, n = 17) in patients with CVD and 2.53 (95%CI: 1.13-5.64, I2: 66%, n = 4) in patients with diabetes mellitus. Linear dose-response analyses revealed that each 50 mg/dL increase in Lp(a) levels was associated with 31% and 15% greater risk of CVD death in the general population and in patients with CVD. No non-linear dose-response association was observed between Lp(a) levels and risk of all-cause or CVD mortality in the general population or in patients with CVD (Pnonlinearity > 0.05). CONCLUSION This study provides further evidence that higher Lp(a) levels are associated with higher risk of all-cause mortality and CVD-death in the general population and in patients with CVD. These findings support the ESC/EAS Guidelines that recommend Lp(a) should be measured at least once in each adult person's lifetime, since our study suggests those with higher Lp(a) might also have higher risk of mortality.
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Affiliation(s)
- Mojgan Amiri
- Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Hamidreza Raeisi-Dehkordi
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Auke J C F Verkaar
- Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, The Netherlands
| | - Yahong Wu
- Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Anniek C van Westing
- Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, The Netherlands
| | - Kirsten A Berk
- Department of Internal Medicine, Division of Pharmacology and Vascular Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Internal Medicine, Division of Dietetics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Wichor M Bramer
- Medical Library, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Dagfinn Aune
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK
- Department of Nutrition, Bjørknes University College, Oslo, Norway
- Department of Endocrinology, Morbid Obesity and Preventive Medicine, Oslo University Hospital, Oslo, Norway
| | - Trudy Voortman
- Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.
- Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, The Netherlands.
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15
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Golledge J, Velu R, Quigley F, Jenkins J, Singh TP. The predictive value of four serum biomarkers for major adverse events in patients with small abdominal aortic aneurysm. J Vasc Surg 2023; 77:1037-1044. [PMID: 36526087 DOI: 10.1016/j.jvs.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 11/26/2022] [Accepted: 12/01/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND The primary aim of this study was to test which of a group of four inflammation and thrombosis biomarkers were independently predictive of major adverse cardiovascular events (MACE) in patients with small abdominal aortic aneurysm (AAA). METHODS A total of 471 participants with a 30- to 54-mm AAA had serum C-reactive protein (CRP), fibrinogen, neutrophil-lymphocyte ratio (NLR), and homocysteine measured. The primary outcome was MACE, which was defined as the first occurrence of myocardial infarction, stroke, or cardiovascular death. The association of biomarkers with events was assessed using Kaplan-Meier and Cox proportional hazard analyses. The net improvement in risk of event categorization with addition of a biomarker to clinical risk factors alone was assessed using net reclassification index. RESULTS Participants were followed for a median of 2.4 years (interquartile range, 0.8-5.4 years), and 102 (21.7%) had a MACE. The incidence of MACE was 13.2% in participants with CRP >3.0 mg/L, compared with 10.1% in those with CRP ≤3.0 mg/L at 2.5 years (P = .047). After adjusting for other risk factors, higher CRP was associated with a significantly higher risk of MACE (hazard ratio, 1.19; 95% confidence interval, 1.05-1.35). None of the other biomarkers were associated with the risk of MACE. According to the net reclassification index, CRP significantly improved the risk classification of MACE compared with clinical risk factors alone. CONCLUSIONS CRP can assist in classification of risk of MACE for patients with small AAA.
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Affiliation(s)
- Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia; Department of Vascular and Endovascular Surgery, The Townsville University Hospital, Townsville, Queensland, Australia; Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, Queensland, Australia.
| | - Ramesh Velu
- Department of Vascular and Endovascular Surgery, The Townsville University Hospital, Townsville, Queensland, Australia
| | | | - Jason Jenkins
- Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Tejas P Singh
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia; Department of Vascular and Endovascular Surgery, The Townsville University Hospital, Townsville, Queensland, Australia
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16
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Lin L, Deng KQ, Chen Z, Lei F, Qin JJ, Huang X, Sun T, Zhang X, Hu Y, Zhang P, Ji YX, Zhang XJ, She ZG, Lu Z, Cai J, Li H. Lipoprotein(a) distribution and its association with carotid arteriopathy in the Chinese population. Atherosclerosis 2023; 372:1-9. [PMID: 37004300 DOI: 10.1016/j.atherosclerosis.2023.03.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 02/19/2023] [Accepted: 03/07/2023] [Indexed: 04/04/2023]
Abstract
BACKGROUND AND AIMS The distribution of lipoprotein(a) [Lp(a)] has not been well-studied in a large population in China. The relationship between Lp(a) and carotid atherosclerosis remains undefined. In this study, we aimed to investigate the distribution of Lp(a) levels and to assess their association with carotid arteriopathy in China. METHODS In this cross-sectional study, 411,634 adults with Lp(a) measurements from 22 health check-up centers were used to investigate Lp(a) distribution in China. Among participants with Lp(a) data, carotid ultrasound was performed routinely at seven health check-up centers covering 75,305 subjects. Carotid intima-media thickness (cIMT) and carotid plaque were used as surrogate biomarkers of carotid arteriopathy. The multivariate logistic regression model was applied to evaluate the association of increased Lp(a) levels with carotid arteriopathy. RESULTS The distribution of Lp(a) concentrations was right-skewed, with a median concentration of 10.60 mg/dL. The proportions of Lp(a) levels ≥30 mg/dL and ≥50 mg/dL were 16.75% and 7.10%, respectively. The median Lp(a) level was higher in females individuals in northern China, and increased with age. Spearman's analysis revealed weak correlations between the Lp(a) concentration as a continuous variable and other lipid profiles. The multiple logistic regression analysis showed that participants with Lp(a) levels ≥50 mg/dL had an increased risk of cIMT ≥1.0 mm (OR = 1.138, 95% CI, 1.071-1.208) and carotid plaque (OR = 1.296, 95% CI, 1.219-1.377) compared with those with Lp(a) levels <50 mg/dL. CONCLUSIONS This is the first study of the Lp(a) distribution in a large population in China. Our findings revealed a positive association between elevated Lp(a) levels (≥50 mg/dL) and increased prevalence of carotid atherosclerosis, which implies an increased risk of cardiovascular disease in the future.
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Affiliation(s)
- Lijin Lin
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China; Institute of Model Animal, Wuhan University, Wuhan, China; Medical Science Research Center, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Ke-Qiong Deng
- Institute of Model Animal, Wuhan University, Wuhan, China; Department of Cardiology, Zhongnan Hospital of Wuhan University, Wuhan, China; Huanggang Institute of Translation Medicine of Yangtze University, Huanggang, China; Department of Cardiology, Huanggang Center Hospital of Yangtze University, Huanggang, China
| | - Ze Chen
- Institute of Model Animal, Wuhan University, Wuhan, China; Department of Cardiology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Fang Lei
- Institute of Model Animal, Wuhan University, Wuhan, China; School of Basic Medical Science, Wuhan University, Wuhan, China
| | - Juan-Juan Qin
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China; Institute of Model Animal, Wuhan University, Wuhan, China
| | - Xuewei Huang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China; Institute of Model Animal, Wuhan University, Wuhan, China
| | - Tao Sun
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China; Institute of Model Animal, Wuhan University, Wuhan, China
| | - Xingyuan Zhang
- Institute of Model Animal, Wuhan University, Wuhan, China; School of Basic Medical Science, Wuhan University, Wuhan, China
| | - Yingying Hu
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China; Institute of Model Animal, Wuhan University, Wuhan, China
| | - Peng Zhang
- Institute of Model Animal, Wuhan University, Wuhan, China; School of Basic Medical Science, Wuhan University, Wuhan, China
| | - Yan-Xiao Ji
- Institute of Model Animal, Wuhan University, Wuhan, China; School of Basic Medical Science, Wuhan University, Wuhan, China
| | - Xiao-Jing Zhang
- Institute of Model Animal, Wuhan University, Wuhan, China; School of Basic Medical Science, Wuhan University, Wuhan, China
| | - Zhi-Gang She
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China; Institute of Model Animal, Wuhan University, Wuhan, China
| | - Zhibing Lu
- Department of Cardiology, Zhongnan Hospital of Wuhan University, Wuhan, China.
| | - Jingjing Cai
- Institute of Model Animal, Wuhan University, Wuhan, China; Department of Cardiology, The Third Xiangya Hospital, Central South University, Changsha, China.
| | - Hongliang Li
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China; Institute of Model Animal, Wuhan University, Wuhan, China; Huanggang Institute of Translation Medicine of Yangtze University, Huanggang, China; Medical Science Research Center, Zhongnan Hospital of Wuhan University, Wuhan, China.
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17
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Impact of lipoprotein(a) levels on primary patency after endovascular therapy for femoropopliteal lesions. Heart Vessels 2023; 38:171-176. [PMID: 35904577 DOI: 10.1007/s00380-022-02151-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 07/20/2022] [Indexed: 01/28/2023]
Abstract
Lipoprotein(a) [Lp(a)] is a risk factor for peripheral artery disease (PAD). However, the relationship between Lp(a) levels and clinical events after endovascular therapy (EVT) for the femoropopliteal artery in PAD patients remains unclear. Thus, this study aimed to assess the impact of Lp(a) levels on primary patency after EVT for de novo femoropopliteal lesions in PAD patients. A retrospective analysis was conducted on 109 patients who underwent EVT for de novo femoropopliteal lesions, and Lp(a) levels were measured before EVT between June 2016 and December 2019. Patients were divided into low Lp(a) [Lp(a) < 30 mg/dL; 78 patients] and high Lp(a) [Lp(a) ≥ 30 mg/dL; 31 patients] groups. The main outcome was primary patency following EVT. Loss of primary patency was defined as a peak systolic velocity ratio > 2.4 on a duplex scan or > 50% stenosis on angiography. Cox proportional hazards analysis was performed to determine whether high Lp(a) levels were independently associated with loss of primary patency. The mean follow-up duration was 28 months. The rates of primary patency were 83 and 76% at 1 year and 75 and 58% at 2 years in the low and high Lp(a) groups, respectively (P = 0.02). After multivariate analysis, High Lp(a)[Lp(a) ≥ 30 mg/dL] (hazard ratio 2.44; 95% CI 1.10-5.44; P = 0.03) and female sex (hazard ratio 2.65; 95% CI 1.27-5.51; P < 0.01) were independent predictors of loss of primary patency. Lp(a) levels might be associated with primary patency after EVT for de novo femoropopliteal lesions.
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18
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Lampsas S, Oikonomou E, Pantelidis P, Theofilis P, Grammatopoulos K, Marathonitis A, Vavuranakis MA, Siasos G, Tousoulis D, Vavuranakis M. Lipoprotein (a) Levels and Abdominal Aortic Aneurysm. A Systematic Review and Meta-analysis. Curr Pharm Des 2022; 28:3492-3499. [PMID: 36424795 DOI: 10.2174/1381612829666221124110920] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 09/29/2022] [Accepted: 10/14/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Several studies have linked high Lipoprotein (a) (Lp(a)) concentrations to cardiovascular events, including the formation of Abdominal Aortic Aneurysms (AAA). We review and meta-analyze existing evidence on the association of Lp(a) levels with AAA. METHODS Studies evaluating the link of Lp(a) with AAA, up to December 27th 2021, were identified by a systematic search of PubMed, SCOPUS, and Web of Science databases. The results were qualitatively and quantitatively synthesized according to PRISMA guidelines. Results are presented as standardized mean differences (SMD) with 95% confidence intervals (CI). RESULTS A total of 5,078 subjects (1,637 patients with AAA vs. 3,441 controls) from 11 studies were included in the meta-analysis, with a mean age of 69.9 years and a male sex prevalence of 85.8%. Based on the qualitative synthesis, high Lp(a) concentrations are linked to abdominal aortic wall degradation and extracellular matrix disarrangement. Moreover, despite the considerable variability among races, high Lp(a) levels are related to increased AAA risk, independently of race differences. Accordingly, patients with AAA displayed significantly higher Lp(a) levels compared to controls (SMD: 0.86, 95% CI: 0.55-1.17, p < 0.001). The outcome was not affected in a sensitivity analysis excluding three outlying studies (SMD: 0.40, 95% CI: 0.22-0.58, p < 0.001). CONCLUSION This meta-analysis indicates the association between high Lp(a) levels and the presence of AAA, although existing literature presents high heterogeneity. Further studies are needed to standardize Lp(a) measurements and to conclude whether Lp(a) can be used as a sensitive biomarker of early presymptomatic AAA diagnosis.
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Affiliation(s)
- Stamatios Lampsas
- 3rd Department of Cardiology, National and Kapodistrian University of Athens, Medical School, Sotiria Chest Disease Hospital, Athens, Greece
| | - Evangelos Oikonomou
- 3rd Department of Cardiology, National and Kapodistrian University of Athens, Medical School, Sotiria Chest Disease Hospital, Athens, Greece.,Cardiometabolic Disease Unit, 3rd Department of Cardiology, National and Kapodistrian University of Athens, Medical School, Sotiria Chest Disease Hospital, Athens, 11527 Greece
| | - Panteleimon Pantelidis
- 3rd Department of Cardiology, National and Kapodistrian University of Athens, Medical School, Sotiria Chest Disease Hospital, Athens, Greece
| | - Panagiotis Theofilis
- Cardiometabolic Disease Unit, 3rd Department of Cardiology, National and Kapodistrian University of Athens, Medical School, Sotiria Chest Disease Hospital, Athens, 11527 Greece
| | - Konstantinos Grammatopoulos
- 3rd Department of Cardiology, National and Kapodistrian University of Athens, Medical School, Sotiria Chest Disease Hospital, Athens, Greece
| | - Anastasios Marathonitis
- 3rd Department of Cardiology, National and Kapodistrian University of Athens, Medical School, Sotiria Chest Disease Hospital, Athens, Greece
| | - Michael A Vavuranakis
- 3rd Department of Cardiology, National and Kapodistrian University of Athens, Medical School, Sotiria Chest Disease Hospital, Athens, Greece
| | - Gerasimos Siasos
- 3rd Department of Cardiology, National and Kapodistrian University of Athens, Medical School, Sotiria Chest Disease Hospital, Athens, Greece.,Cardiometabolic Disease Unit, 3rd Department of Cardiology, National and Kapodistrian University of Athens, Medical School, Sotiria Chest Disease Hospital, Athens, 11527 Greece.,Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Dimitris Tousoulis
- 1st Department of Cardiology, National and Kapodistrian University of Athens, Medical School, Hippokration General Hospital, Athens, Greece
| | - Manolis Vavuranakis
- 3rd Department of Cardiology, National and Kapodistrian University of Athens, Medical School, Sotiria Chest Disease Hospital, Athens, Greece
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19
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Williams MC, Dweck MR. Unraveling the Association Between Lipoprotein(a) and Cardiovascular Events With Coronary Computed Tomography Angiography. Circ Cardiovasc Imaging 2022; 15:e015035. [PMID: 36503253 DOI: 10.1161/circimaging.122.015035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Michelle C Williams
- British Heart Foundation Center for Cardiovascular Science, University of Edinburgh, United Kingdom
| | - Marc R Dweck
- British Heart Foundation Center for Cardiovascular Science, University of Edinburgh, United Kingdom
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20
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Zierfuss B, Höbaus C, Feldscher A, Hannes A, Mrak D, Koppensteiner R, Stangl H, Schernthaner GH. Lipoprotein (a) and long-term outcome in patients with peripheral artery disease undergoing revascularization. Atherosclerosis 2022; 363:94-101. [PMID: 36280470 DOI: 10.1016/j.atherosclerosis.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 09/09/2022] [Accepted: 10/04/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS Despite low LDL-C goals, the residual risk for further cardiovascular (CV) events in patients with peripheral artery disease (PAD) remains high. Lipoprotein (a) (Lp(a)) is a known risk factor for PAD incidence, but little is known regarding the outcome in patients with symptomatic PAD. Thus, this study investigates Lp(a) and CV mortality in PAD after endovascular repair. METHODS A total of 1222 patients with PAD in two cohorts according to Lp(a) assay in nmol/L (n = 964, Lip-LEAD-A) or mg/dl (n = 258, Lip-LEAD-B) were followed up for 4.3 (IQR 3.0-5.6) or 7.6 (IQR 3.2-8.1) years. Lp(a) was measured before endovascular repair for either intermittent claudication (IC) or critical limb ischemia (CLI). Outcome information was obtained from the federal death registry. RESULTS In Lip-LEAD-A, 141 CV-deaths occurred (annual calculated CV-death rate 3.4%), whereas 64 CV-deaths were registered in Lip-LEAD-B (annual calculated CV-death rate 3.3%). After adjustment for traditional CV risk factors Lp(a) was neither associated with outcome in Lip-LEAD-A (highest tertile HR 1.47, 95%CI [0.96-2.24]) nor in Lip-LEAD-B (highest tertile HR 1.34 [0.70-2.58]). Subanalyses for IC (HR 1.37 [0.74-2.55]; HR 1.10 [0.44-2.80], CLI (HR 1.55 [0.86-2.80], HR 3.01 [0.99-9.10]), or concomitant coronary artery disease (CAD; HR 1.34 [0.71-2.54]; HR 1.21 [0.46-3.17]) failed to show a significant association between Lp(a) and CV-mortality. CONCLUSIONS In this large-scale cohort of symptomatic PAD no association of elevated Lp(a) with CV mortality was found over a median observation period of 5 years. Thus, an even longer study including asymptomatic patients is warranted.
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Affiliation(s)
- Bernhard Zierfuss
- Division of Angiology, Department of Medicine 2, Medical University of Vienna, Austria
| | - Clemens Höbaus
- Division of Angiology, Department of Medicine 2, Medical University of Vienna, Austria
| | - Anna Feldscher
- Division of Angiology, Department of Medicine 2, Medical University of Vienna, Austria
| | - Antonia Hannes
- Division of Angiology, Department of Medicine 2, Medical University of Vienna, Austria
| | - Daniel Mrak
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Austria
| | - Renate Koppensteiner
- Division of Angiology, Department of Medicine 2, Medical University of Vienna, Austria
| | - Herbert Stangl
- Center for Pathobiochemistry and Genetics, Institute for Medical Chemistry, Medical University of Vienna, Austria
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21
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Kronenberg F. Studies on lipoprotein(a) and outcomes in peripheral arterial disease: One must not compare apples with pears. Atherosclerosis 2022; 363:71-72. [PMID: 36424295 DOI: 10.1016/j.atherosclerosis.2022.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 11/04/2022] [Indexed: 11/14/2022]
Affiliation(s)
- Florian Kronenberg
- Institute of Genetic Epidemiology, Medical University of Innsbruck, Innsbruck, Austria.
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22
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Guédon AF, De Freminville JB, Mirault T, Mohamedi N, Rance B, Fournier N, Paul JL, Messas E, Goudot G. Association of Lipoprotein(a) Levels With Incidence of Major Adverse Limb Events. JAMA Netw Open 2022; 5:e2245720. [PMID: 36480201 PMCID: PMC9856359 DOI: 10.1001/jamanetworkopen.2022.45720] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
IMPORTANCE High lipoprotein(a) (Lp[a]) levels are involved in the development of cardiovascular events, particularly in myocardial infarction, stroke, and peripheral artery disease. Studies assessing the Lp(a) levels associated with adverse lower-limb events are lacking. OBJECTIVE To assess the association between Lp(a) levels and incidence of major adverse limb events in unselected hospitalized patients. DESIGN, SETTING, AND PARTICIPANTS This large retrospective monocentric cohort study was conducted from January 1, 2000, to December 31, 2020. Data were derived from the clinical information system of the Hôpital Européen Georges-Pompidou, a Paris-based university hospital. Patients who underwent at least 1 Lp(a) measurement at the center during the study period were included. Patients who had no follow-up data or who had the first Lp(a) measurement after the study outcome had occurred were excluded. Data analyses were performed from May 2021 to January 2022. MAIN OUTCOMES AND MEASURES The primary outcome was the first inpatient major adverse limb event, defined as a major amputation, peripheral endovascular revascularization, or peripheral surgical revascularization, during follow-up. Secondary outcomes included individual components of the primary outcome. Lipoprotein(a) levels were categorized as follows: normal (<50 mg/dL), high (50 to <134 mg/dL), and very high (≥134 mg/dL); to convert Lp(a) values to milligrams per liter, multiply by 0.1. RESULTS A total of 16 513 patients (median [IQR] age, 58.2 [49.0-66.7] years; 9774 men [59.2%]) were included in the cohort. The median (IQR) Lp(a) level was 24 (10.0-60.0) mg/dL. The 1-year incidence of major adverse limb event was 2.44% in the overall population and 4.54% among patients with very high Lp(a) levels. High (adjusted accelerated failure time [AFT] exponential estimate: 0.43; 95% CI, 0.24-0.78; Benjamini-Hochberg-corrected P = .01) and very high (adjusted AFT exponential estimate: 0.17; 95% CI, 0.07-0.40; Benjamini-Hochberg-corrected P < .001) Lp(a) levels were independently associated with an increased risk of major adverse limb event. CONCLUSIONS AND RELEVANCE Results of this study showed that higher Lp(a) levels were independently associated with an increased risk of a major adverse limb event in hospitalized patients. The Lp(a) measurement needs to be taken into account to improve lower-limb vascular risk assessment.
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Affiliation(s)
- Alexis F. Guédon
- Vascular Medicine Department, Georges Pompidou European Hospital, Assistance Publique–Hôpitaux de Paris (APHP), Université Paris Cité, Paris, France
| | - Jean-Baptiste De Freminville
- Vascular Medicine Department, Georges Pompidou European Hospital, Assistance Publique–Hôpitaux de Paris (APHP), Université Paris Cité, Paris, France
| | - Tristan Mirault
- Vascular Medicine Department, Georges Pompidou European Hospital, Assistance Publique–Hôpitaux de Paris (APHP), Université Paris Cité, Paris, France
- Paris Cardiovascular Research Center (PARCC), Institut National de la Santé et de la Recherche Médicale (INSERM) U970, Université Paris Cité, Paris, France
| | - Nassim Mohamedi
- Vascular Medicine Department, Georges Pompidou European Hospital, Assistance Publique–Hôpitaux de Paris (APHP), Université Paris Cité, Paris, France
| | - Bastien Rance
- Department of Medical Informatics, Georges Pompidou European Hospital, APHP, Université Paris Cité, Paris, France
| | - Natalie Fournier
- Biology Department, Biochemistry Laboratory, Georges Pompidou European Hospital, APHP, Université Paris Cité, Paris, France
- Lip(Sys)2-EA7357, Athérosclérose et Macrophages: Impact Des Phospholipides e Des Fonctions Mitochondriales Sur l'efflux du Cholestérol Cellulaire, Université Paris-Saclay, UFR de Pharmacie, Chatenay-Malabry, France
| | - Jean-Louis Paul
- Biology Department, Biochemistry Laboratory, Georges Pompidou European Hospital, APHP, Université Paris Cité, Paris, France
- Lip(Sys)2-EA7357, Athérosclérose et Macrophages: Impact Des Phospholipides e Des Fonctions Mitochondriales Sur l'efflux du Cholestérol Cellulaire, Université Paris-Saclay, UFR de Pharmacie, Chatenay-Malabry, France
| | - Emmanuel Messas
- Vascular Medicine Department, Georges Pompidou European Hospital, Assistance Publique–Hôpitaux de Paris (APHP), Université Paris Cité, Paris, France
- Paris Cardiovascular Research Center (PARCC), Institut National de la Santé et de la Recherche Médicale (INSERM) U970, Université Paris Cité, Paris, France
| | - Guillaume Goudot
- Vascular Medicine Department, Georges Pompidou European Hospital, Assistance Publique–Hôpitaux de Paris (APHP), Université Paris Cité, Paris, France
- Paris Cardiovascular Research Center (PARCC), Institut National de la Santé et de la Recherche Médicale (INSERM) U970, Université Paris Cité, Paris, France
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23
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Chakraborty A, Chan DC, Ellis KL, Pang J, Barnett W, Woodward AM, Vorster M, Norman R, Moses EK, Watts GF. Cascade testing for elevated lipoprotein(a) in relatives of probands with high lipoprotein(a). Am J Prev Cardiol 2022; 10:100343. [PMID: 35517871 PMCID: PMC9062205 DOI: 10.1016/j.ajpc.2022.100343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 04/05/2022] [Accepted: 04/14/2022] [Indexed: 01/21/2023] Open
Abstract
Objective Elevated lipoprotein(a) [Lp(a)] is a common inherited condition associated with cardiovascular disease. This study investigated whether cascade testing for Lp(a) was effective in detecting new cases of elevated Lp(a) in families. Methods Relatives from adult probands with Lp(a) concentration ≥100 mg/dL were tested for elevated Lp(a) (≥50 mg/dL) via a cascade testing program in a tertiary hospital setting. The prevalence and yield of detecting new cases of elevated Lp(a) among the relatives were assessed. Results Of the 83 probands, 43.4% had familial combined hyperlipidemia (FCHL) and 34.9% common hypercholesterolemia (CH). Among 182 relatives tested (151 adults and 31 children), elevated Lp(a) was found in 68.1%, with 32.9% having Lp(a) between 50 and 99 mg/dL and 35.2% having Lp(a) ≥100 mg/dL. One new case of elevated Lp(a) ≥50 mg/dL was identified for every 1.5 relatives tested and 1 new case of elevated Lp(a) ≥100 mg/dL for every 2.8 relatives tested. The proportion of relatives detected with elevated Lp(a) was significantly higher when tested from probands with Lp(a) >150 mg/dL compared with those with Lp(a) between 100 and 150 mg/dL (81.1% vs. 55.5%; P = 0.001). The concordance rates (kappa coefficient) for the detection of elevated Lp(a) with FCHL and CH were 34.8% (0.026) and 53.2% (0.099), respectively. Conclusion Cascade testing for elevated Lp(a) from affected probands with phenotypic dyslipidemia is highly effective in identifying new cases of high Lp(a) in families. The yield of detecting elevated Lp(a) is greater when probands have higher levels of Lp(a) and exceeds the detection of relatives with FCHL and CH.
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Affiliation(s)
- Anindita Chakraborty
- Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - Dick C. Chan
- Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - Katrina L. Ellis
- Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - Jing Pang
- Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - Wendy Barnett
- Lipid Disorders Clinic, Department of Cardiology and Internal Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Ann Marie Woodward
- Lipid Disorders Clinic, Department of Cardiology and Internal Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Mary Vorster
- Lipid Disorders Clinic, Department of Cardiology and Internal Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Richard Norman
- School of Population Health, Curtin University, Perth, Western Australia, Australia
| | - Eric K. Moses
- Menzies Institute for Medical Research, University of Tasmania, Tasmania, Australia
| | - Gerald F. Watts
- Medical School, University of Western Australia, Perth, Western Australia, Australia
- Lipid Disorders Clinic, Department of Cardiology and Internal Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
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24
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Arsenault BJ, Kamstrup PR. Lipoprotein(a) and cardiovascular and valvular diseases: A genetic epidemiological perspective. Atherosclerosis 2022; 349:7-16. [PMID: 35606078 DOI: 10.1016/j.atherosclerosis.2022.04.015] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 04/08/2022] [Accepted: 04/14/2022] [Indexed: 12/12/2022]
Abstract
Rates of atherosclerotic cardiovascular diseases (CVD) in the Western world have spectacularly decreased over the past 50 years. However, a substantial proportion of high-risk patients still develop heart attacks, strokes and valvular heart diseases despite benefiting from state-of-the-art treatments including lipid-lowering therapies. Over the past 10-15 years, it has become increasingly clear that Lipoprotein(a) (Lp[a]) is a critical component of this so-called residual risk. Genetic association studies revealed that Lp(a) is robustly, independently and causally associated with a broad range of cardiovascular and valvular heart diseases. Up to 1 billion people around the globe may have an Lp(a) level that places them in a high-risk category. Lp(a) is strongly associated with calcific aortic valve stenosis (CAVS), coronary artery disease (CAD), peripheral arterial disease (PAD) and to a lesser extent with ischemic stroke (IS) and heart failure (HF). Because of this strong association with cardiovascular and valvular heart diseases, Lp(a) even emerged as one of the most important genetic determinants of human lifespan and healthspan. Here, we review the evidence from the largest and most informative genetic association studies and prospective studies that have investigated the association between Lp(a) and human lifespan, healthspan, CVD, CAVS and non-cardiovascular diseases. We present Lp(a) threshold values that may be clinically relevant and identify other cardiovascular risk factors that may modulate the absolute risk of CVD in individuals with high Lp(a) levels. Finally, we identify key clinical and research questions that require further investigation to eventually and optimally reduce CVD risk in patients with high Lp(a) levels.
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Affiliation(s)
- Benoit J Arsenault
- Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec, Canada; Department of Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada.
| | - Pia R Kamstrup
- Department of Clinical Biochemistry and, Copenhagen University Hospital - Herlev and Gentofte, Borgmester Ib Juuls Vej 73, DK-2730, Herlev, Denmark; The Copenhagen General Population Study, Copenhagen University Hospital - Herlev and Gentofte, Borgmester Ib Juuls Vej 73, DK-2730, Herlev, Denmark.
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25
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Masson W, Lobo M, Barbagelata L, Molinero G, Bluro I, Nogueira JP. Elevated lipoprotein (a) levels and risk of peripheral artery disease outcomes: A systematic review. Vasc Med 2022; 27:385-391. [PMID: 35466849 DOI: 10.1177/1358863x221091320] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Despite strong association of elevated lipoprotein (a) (Lp(a)) levels with incident coronary and cerebrovascular disease, data for incident peripheral artery disease (PAD) are less robust. The main objective of the present systematic review was to analyze the association between elevated Lp(a) levels and PAD outcomes. METHODS This systematic review was performed according to PRISMA guidelines. A literature search was performed to detect randomized clinical trials or observational studies with a cohort design that evaluated the association between Lp(a) levels and PAD outcomes. RESULTS Fifteen studies including 493,650 subjects were identified and considered eligible for this systematic review. This systematic review showed that the vast majority of the studies reported a significant association between elevated Lp(a) levels and the risk of PAD outcomes. The elevated Lp(a) levels were associated with a higher risk of incident claudication (RR: 1.20), PAD progression (HR: 1.41), restenosis (HR: 6.10), death and hospitalization related to PAD (HR: 1.37), limb amputation (HR: 22.75), and lower limb revascularization (HR: 1.29 and 2.90). In addition, the presence of elevated Lp(a) values were associated with a higher risk of combined PAD outcomes, with HRs in a range between 1.14 and 2.80, despite adjusting for traditional risk factors. Heterogeneity of results can be explained by different patient populations studied and varying Lp(a) cut-off points of Lp(a) analyzed. CONCLUSION This systematic review suggests that evidence is available to support an independent positive association between Lp(a) levels and the risk of future PAD outcomes. PROSPERO Registration No.: 289253.
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Affiliation(s)
- Walter Masson
- Council of Epidemiology and Cardiovascular Prevention, Argentine Society of Cardiology, Buenos Aires, Argentina.,Cardiology Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Martín Lobo
- Council of Epidemiology and Cardiovascular Prevention, Argentine Society of Cardiology, Buenos Aires, Argentina.,Cardiology Department, Hospital Militar Campo de Mayo, Buenos Aires, Argentina
| | - Leandro Barbagelata
- Cardiology Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Graciela Molinero
- Council of Epidemiology and Cardiovascular Prevention, Argentine Society of Cardiology, Buenos Aires, Argentina
| | - Ignacio Bluro
- Cardiology Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Juan P Nogueira
- Centro de Investigación en Endocrinología, Nutrición y Metabolismo (CIENM), Facultad de Ciencias de la Salud, Universidad Nacional de Formosa, Formosa, Formosa Province, Argentina
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Verwer MC, Waissi F, Mekke JM, Dekker M, Stroes ESG, de Borst GJ, Kroon J, Hazenberg CEVB, de Kleijn DPV. High lipoprotein(a) is associated with major adverse limb events after femoral artery endarterectomy. Atherosclerosis 2021; 349:196-203. [PMID: 34857353 DOI: 10.1016/j.atherosclerosis.2021.11.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 10/25/2021] [Accepted: 11/17/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUNDS AND AIMS Elevated lipoprotein(a) (Lp[a]) has been identified as a causal risk factor for cardiovascular disease including peripheral arterial disease (PAD). Although Lp(a) is associated with the diagnosis of PAD, it remains elusive whether there is an association of Lp(a) with cardiovascular and limb events in patients with severe PAD. METHODS Preoperative plasma Lp(a) levels were measured in 384 consecutive patients that underwent iliofemoral endarterectomy and were included in the Athero-Express biobank. Our primary objective was to assess the association of Lp(a) levels with Major Adverse Limb Events (MALE). Our secondary objective was to relate Lp(a) levels to Major Adverse Cardiovascular Events (MACE) and femoral plaque composition that was acquired from baseline surgery. RESULTS During a median follow-up time of 5.6 years, a total of 225 MALE were recorded in 132 patients. Multivariable analysis, including history of peripheral intervention, age, diabetes mellitus, end stage renal disease and PAD disease stages, showed that Lp(a) was independently associated with first (HR of 1.36 (95% CI 1.02-1.82) p = .036) and recurrent MALE (HR 1.36 (95% CI 1.10-1.67) p = .004). A total of 99 MACE were recorded but Lp(a) levels were not associated with MACE.sLp(a) levels were significantly associated with a higher presence of smooth muscle cells in the femoral plaque, although this was not associated with MALE or MACE. CONCLUSIONS Plasma Lp(a) is independently associated with first and consecutive MALE after iliofemoral endarterectomy. Hence, in patients who undergo iliofemoral endarterectomy, Lp(a) could be considered as a biomarker to enhance risk stratification for future MALE.
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Affiliation(s)
- Maarten C Verwer
- Department of Vascular Surgery, University Medical Center Utrecht, PO Box 85500, 3508, GA, Utrecht, the Netherlands.
| | - Farahnaz Waissi
- Department of Vascular Surgery, University Medical Center Utrecht, PO Box 85500, 3508, GA, Utrecht, the Netherlands; Netherlands Heart Institute, Moreelsepark 1, 3511, EP, Utrecht, the Netherlands; Department of Cardiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, 1105, AZ, the Netherlands
| | - Joost M Mekke
- Department of Vascular Surgery, University Medical Center Utrecht, PO Box 85500, 3508, GA, Utrecht, the Netherlands
| | - Mirthe Dekker
- Department of Vascular Surgery, University Medical Center Utrecht, PO Box 85500, 3508, GA, Utrecht, the Netherlands; Netherlands Heart Institute, Moreelsepark 1, 3511, EP, Utrecht, the Netherlands; Department of Cardiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, 1105, AZ, the Netherlands
| | - Erik S G Stroes
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Meibergdreef 9, Amsterdam, 1105, AZ, the Netherlands
| | - Gert J de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, PO Box 85500, 3508, GA, Utrecht, the Netherlands
| | - Jeffrey Kroon
- Department of Experimental Vascular Medicine, Amsterdam Cardiovascular Sciences, Meibergdreef 9, Amsterdam, 1105, AZ, the Netherlands
| | - Constantijn E V B Hazenberg
- Department of Vascular Surgery, University Medical Center Utrecht, PO Box 85500, 3508, GA, Utrecht, the Netherlands
| | - Dominique P V de Kleijn
- Department of Vascular Surgery, University Medical Center Utrecht, PO Box 85500, 3508, GA, Utrecht, the Netherlands; Laboratory of Experimental Cardiology, University Medical Center Utrecht, PO Box 85500, 3508, GA, Utrecht, the Netherlands; Netherlands Heart Institute, Moreelsepark 1, 3511, EP, Utrecht, the Netherlands.
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Chakraborty A, Pang J, Chan DC, Ellis KL, Hooper AJ, Bell DA, Burnett JR, Moses EK, Watts GF. Cascade testing for elevated lipoprotein(a) in relatives of probands with familial hypercholesterolaemia and elevated lipoprotein(a). Atherosclerosis 2021; 349:219-226. [PMID: 34862044 DOI: 10.1016/j.atherosclerosis.2021.11.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 10/08/2021] [Accepted: 11/03/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Familial hypercholesterolaemia (FH) and elevated plasma lipoprotein(a) [Lp(a)] are inherited conditions independently associated with atherosclerotic cardiovascular disease. This study investigated the detection of new cases of elevated Lp(a) during cascade testing of relatives of probands with a definite diagnosis of FH and elevated Lp(a) (≥50 mg/dL). METHODS Relatives from 62 adult probands were tested for FH genetically and for elevated Lp(a) using an immunoassay. The prevalence and yield of new cases of FH with or without elevated Lp(a) among relatives and the association between the detection of elevated Lp(a) and the Lp(a) concentration of the probands were assessed. RESULTS Among 162 relatives tested (136 adults and 26 children), the prevalence of FH and elevated Lp(a) was 60.5% and 41.4%, respectively: FH alone was detected in 31.5%, elevated Lp(a) alone in 12.3%, FH with elevated Lp(a) in 29.0%, and neither disorder in 27.2% of the relatives. Cascade testing detected a new case of FH, elevated Lp(a) and FH with elevated Lp(a) for every 1.5, 2.1 and 3.0 relatives tested, respectively. The proportion of relatives detected with elevated Lp(a) was significantly higher when tested from probands with Lp(a) ≥100 mg/dL compared with those from probands with Lp(a) between 50 and 99 mg/dL (53% vs 34%, p = 0.018). The concordance between the detection of FH and elevated Lp(a) was 56.2% (kappa statistic 0.154), indicating a poor agreement. CONCLUSIONS A dual approach to cascade testing families for FH and high Lp(a) from appropriate probands can effectively identify not only new cases of FH, but also new cases of elevated Lp(a) with or without FH. The findings accord with the co-dominant and independent heritability of FH and Lp(a).
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Affiliation(s)
- Anindita Chakraborty
- Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - Jing Pang
- Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - Dick C Chan
- Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - Katrina L Ellis
- Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - Amanda J Hooper
- Medical School, University of Western Australia, Perth, Western Australia, Australia; Department of Clinical Biochemistry, PathWest Laboratory Medicine WA, Royal Perth Hospital and Fiona Stanley Hospital Network, Perth, Western Australia, Australia
| | - Damon A Bell
- Medical School, University of Western Australia, Perth, Western Australia, Australia; Department of Clinical Biochemistry, PathWest Laboratory Medicine WA, Royal Perth Hospital and Fiona Stanley Hospital Network, Perth, Western Australia, Australia; Lipid Disorders Clinic, Department of Cardiology and Internal Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
| | - John R Burnett
- Medical School, University of Western Australia, Perth, Western Australia, Australia; Department of Clinical Biochemistry, PathWest Laboratory Medicine WA, Royal Perth Hospital and Fiona Stanley Hospital Network, Perth, Western Australia, Australia; Lipid Disorders Clinic, Department of Cardiology and Internal Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Eric K Moses
- Menzies Institute for Medical Research, University of Tasmania, Tasmania, Australia
| | - Gerald F Watts
- Medical School, University of Western Australia, Perth, Western Australia, Australia; Lipid Disorders Clinic, Department of Cardiology and Internal Medicine, Royal Perth Hospital, Perth, Western Australia, Australia.
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Golledge J, Velu R, Quigley F, Jenkins J, Singh TP. Cohort Study Examining the Association of Immunosuppressant Drug Prescription With Major Adverse Cardiovascular and Limb Events in Patients With Peripheral Artery Disease. Ann Vasc Surg 2021; 78:310-320. [PMID: 34537348 DOI: 10.1016/j.avsg.2021.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 06/21/2021] [Accepted: 07/01/2021] [Indexed: 11/01/2022]
Abstract
AIM Immune activation is strongly implicated in atherosclerotic plaque instability, however, the effect of immunosuppressant drugs on cardiovascular events in patients with peripheral artery disease (PAD) is not known. The aim of this study was to assess whether prescription of one or more immune suppressant drugs was associated with a lower risk of major adverse cardiovascular (MACE; i.e. myocardial infarction, stroke or cardiovascular events) or limb events (MALE; i.e. major amputation or requirement for peripheral revascularization) in patients with PAD. METHODS A total of 1506 participants with intermittent claudication (n = 872) or chronic limb threatening ischemia (CLTI; n = 634) of whom 53 (3.5%) were prescribed one or more immunosuppressant drugs (prednisolone 41; methotrexate 17; leflunomide 5; hydroxychloroquine 3; azathioprine 2; tocilizumab 2; mycophenolate 1; sulfasalazine 1; adalimumab 1) were recruited from 3 Australian hospitals. Participants were followed for a median of 3.9 (inter-quartile range 1.2, 7.3) years. The association of immunosuppressant drug prescription with MACE or MALE was examined using Cox proportional hazard analyses. RESULTS After adjusting for other risk factors, prescription of an immunosuppressant drug was associated with a significantly greater risk of MACE (Hazard ratio, HR, 1.83, 95% confidence intervals, CI, 1.11, 3.01; P = 0.017) but not MALE (HR 1.32, 95% CI 0.90, 1.92; P = 0.153). In a sub-analysis restricted to participants with CLTI findings were similar: MACE (HR 2.44, 95% CI 1.32, 4.51; P = 0.005); MALE (HR 1.38, 95% CI 0.87, 2.19; P = 0.175); major amputation (HR 1.37, 95% CI 0.49, 3.86; P = 0.547). CONCLUSIONS This cohort study suggested that immunosuppressant drug therapy is associated with a greater risk of MACE amongst patients with PAD.
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Affiliation(s)
- Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia; The Department of Vascular and Endovascular Surgery, The Townsville University Hospital, Townsville, Queensland, Australia; The Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, Queensland, Australia.
| | - Ramesh Velu
- The Department of Vascular and Endovascular Surgery, The Townsville University Hospital, Townsville, Queensland, Australia
| | - Frank Quigley
- The Mater Hospital, Townsville, Queensland, Australia
| | - Jason Jenkins
- Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Tejas P Singh
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia; The Department of Vascular and Endovascular Surgery, The Townsville University Hospital, Townsville, Queensland, Australia
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Parthymos I, Kostapanos MS, Mikhailidis DP, Florentin M. Lipoprotein (a) as a treatment target for cardiovascular disease prevention and related therapeutic strategies: a critical overview. Eur J Prev Cardiol 2021; 29:739-755. [PMID: 34389859 DOI: 10.1093/eurjpc/zwab052] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 11/30/2020] [Accepted: 03/15/2021] [Indexed: 12/21/2022]
Abstract
Advances in several fields of cardiovascular (CV) medicine have produced new treatments (e.g. to treat dyslipidaemia) that have proven efficacy in terms of reducing deaths and providing a better quality of life. However, the burden of CV disease (CVD) remains high. Thus, there is a need to search for new treatment targets. Lipoprotein (a) [Lp(a)] has emerged as a potential novel target since there is evidence that it contributes to CVD events. In this narrative review, we present the current evidence of the potential causal relationship between Lp(a) and CVD and discuss the likely magnitude of Lp(a) lowering required to produce a clinical benefit. We also consider current and investigational treatments targeting Lp(a), along with the potential cost of these interventions.
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Affiliation(s)
- Ioannis Parthymos
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina 45110, Greece
| | - Michael S Kostapanos
- Department of General Medicine, Lipid Clinic, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London NW3 2QG, UK
| | - Matilda Florentin
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina 45110, Greece
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30
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Golledge J, Drovandi A, Velu R, Moxon J. Cohort study examining the relationship between remoteness and requirement for surgery to treat peripheral artery disease at a tertiary hospital in North Queensland. Aust J Rural Health 2021; 29:512-520. [PMID: 34346526 DOI: 10.1111/ajr.12776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 05/18/2021] [Accepted: 06/18/2021] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To assess whether outcomes of peripheral artery disease (PAD) were related to remoteness from the treating tertiary vascular centre. SETTING AND PARTICIPANTS Participants with a variety of types of occlusive and aneurysmal diseases were recruited from a tertiary hospital in North Queensland, Australia. Remoteness was assessed by residence outside Townsville and estimated distance to the vascular centre. Cox proportional hazard analyses were used to examine the association of remoteness with outcome. DESIGN Cohort study. MAIN OUTCOME MEASURES The primary outcome was requirement for surgery to treat PAD. Secondary outcomes were major adverse cardiovascular events (MACE) and all-cause mortality. RESULTS Of 2487 patients recruited, 1274 (51.2%) had at least one PAD surgery, 720 (29.0%) at least one MACE, and 909 (36.6%) died during a median of 4.2 (inter-quartile range 1.3-7.7) years. Compared to Townsville residents (n = 1287), those resident outside Townsville (n = 1200) had higher rates of PAD surgery (hazard ratio, HR 1.55, 95% confidence intervals, CI, 1.39, 1.73) but no increased risk of MACE (HR 1.00, 95% CI 0.86, 1.16) or death (HR 1.03, 95% CI 0.90, 1.17). This association was attenuated when adjusting for distance from the vascular centre (HR 1.31, 95% CI 1.14, 1.51). Patients in the highest quartile of distance presented with lower ankle-brachial pressure index, more severe carotid artery disease and larger aortic diameter. CONCLUSIONS People with PAD in North Queensland residing furthest from the tertiary hospital presented with more severe artery disease and had greater rates of PAD surgery.
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Affiliation(s)
- Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, QLD, Australia.,The Department of Vascular and Endovascular Surgery, Townsville University Hospital, Townsville, QLD, Australia
| | - Aaron Drovandi
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, QLD, Australia
| | - Ramesh Velu
- The Department of Vascular and Endovascular Surgery, Townsville University Hospital, Townsville, QLD, Australia
| | - Joseph Moxon
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, QLD, Australia
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Abstract
Peripheral artery disease (PAD) is a manifestation of systemic atherosclerosis. Modifiable risk factors including cigarette smoking, dyslipidemia, diabetes, poor diet quality, obesity, and physical inactivity, along with underlying genetic factors contribute to lower extremity atherosclerosis. Patients with PAD often have coexistent coronary or cerebrovascular disease, and increased likelihood of major adverse cardiovascular events, including myocardial infarction, stroke and cardiovascular death. Patients with PAD often have reduced walking capacity and are at risk of acute and chronic critical limb ischemia leading to major adverse limb events, such as peripheral revascularization or amputation. The presence of polyvascular disease identifies the highest risk patient group for major adverse cardiovascular events, and patients with prior critical limb ischemia, prior lower extremity revascularization, or amputation have a heightened risk of major adverse limb events. Medical therapies have demonstrated efficacy in reducing the risk of major adverse cardiovascular events and major adverse limb events, and improving function in patients with PAD by modulating key disease determining pathways including inflammation, vascular dysfunction, and metabolic disturbances. Treatment with guideline-recommended therapies, including smoking cessation, lipid lowering drugs, optimal glucose control, and antithrombotic medications lowers the incidence of major adverse cardiovascular events and major adverse limb events. Exercise training and cilostazol improve walking capacity. The heterogeneity of risk profile in patients with PAD supports a personalized approach, with consideration of treatment intensification in those at high risk of adverse events. This review highlights the medical therapies currently available to improve outcomes in patients with PAD.
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Affiliation(s)
- Marc P Bonaca
- Division of Cardiology, CPC Clinical Research, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO (M.P.B.)
| | - Naomi M Hamburg
- Department of Medicine, Whitaker Cardiovascular Institute, Boston University School of Medicine, Section of Vascular Biology, Boston Medical Center, MA (N.M.H.)
| | - Mark A Creager
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, NH (M.A.C.)
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Golledge J, Drovandi A. Evidence-Based Recommendations for Medical Management of Peripheral Artery Disease. J Atheroscler Thromb 2021; 28:573-583. [PMID: 33746159 PMCID: PMC8219542 DOI: 10.5551/jat.62778] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 02/08/2021] [Indexed: 12/15/2022] Open
Abstract
Patients with lower limb artery stenosis or occlusion (peripheral artery disease; PAD) have been determined to be at very high risk of both major adverse cardiovascular events, such as myocardial infarction and stroke, and major adverse limb events, such as amputation and requirement for artery surgery.Effective medical management has been identified as key in reducing this risk; however, this is often poorly implemented in clinical practice. Thus, the aim of this narrative review was to summarize the current evidence on the medical management of PAD in order to inform clinicians and highlight recommendations for clinical practice. International guidelines, randomized controlled trials, and relevant systematic reviews and meta-analyses have been included in this study. The focus was the management of the key modifiable risk factors to mitigate possible adverse events through prescription of anti-platelet and anticoagulation drugs and medications to control low-density lipoprotein cholesterol, blood pressure, and diabetes and aid smoking cessation. The available evidence from randomized clinical trials provide a strong rationale for the need for holistic medical management programs that are effective in achieving uptake of these medical therapies in patients with PAD. In conclusion, people with PAD have some of the highest adverse event rates among those with cardiovascular diseases. Secondary preventive measures have been proven effective in reducing these adverse events; however, they remain to be adequately implemented. Thus, the need for an effective implementation program has emerged to reduce adverse events in this patient group.
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Affiliation(s)
- Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University,Townsville, Queensland, Australia
- The Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, Queensland, Australia
- The Department of Vascular and Endovascular Surgery, The Townsville University Hospital, Townsville, Queensland, Australia
| | - Aaron Drovandi
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University,Townsville, Queensland, Australia
- The Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, Queensland, Australia
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Chakraborty A, Pang J, Chan DC, Barnett W, Woodward AM, Vorster M, Watts GF. Effectiveness of proprotein convertase subtilisin/kexin-9 monoclonal antibody treatment on plasma lipoprotein(a) concentrations in patients with elevated lipoprotein(a) attending a clinic. Clin Cardiol 2021; 44:805-813. [PMID: 33955565 PMCID: PMC8207967 DOI: 10.1002/clc.23607] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 03/22/2021] [Accepted: 03/29/2021] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Lipoprotein(a) (Lp[a]) is a causal risk factor for atherosclerotic cardiovascular disease (ASCVD). Proprotein convertase subtilisin/kexin-9 monoclonal antibodies (PCSK9mAbs) can lower Lp(a) levels in clinical trials, but their effects in patients with elevated Lp(a) in clinical practice remain unclear. AIMS To investigate the effectiveness and safety of PCSK9mAbs in lowering plasma Lp(a) in patients with elevated Lp(a) concentrations in a lipid clinic. METHODS This was an open-label study of 53 adult patients with elevated Lp(a) concentration (≥0.5 g/L). Clinical, biochemical, and safety data were collected before and on treatment with evolocumab or alirocumab over a mean period of 11 months. RESULTS Treatment with a PCSK9mAb resulted in a significant reduction of 0.29 g/L (-22%) in plasma Lp(a) concentration (p<.001). There were also significant reductions in low-density lipoprotein-cholesterol (LDL-C) (-53%), remnant-cholesterol (-12%) and apolipoprotein B (-43%) concentrations. The change in Lp(a) concentration was significantly different from a comparable group of 35 patients with elevated Lp(a) who were not treated with a PCSK9mAb (-22% vs. -2%, p<.001). The reduction in Lp(a) concentration was not associated with the corresponding changes in LDL-C, remnant-cholesterol, and apolipoprotein B (p>.05 in all). 7.5% and 47% of the patients attained a target concentration of Lp(a) <0.5 g/L and LDL-C <1.8 mmol/L, respectively. PCSK9mAbs were well tolerated, the common adverse effects being pharyngitis (9.4%), nasal congestion (7.6%), myalgia (9.4%), diarrhoea (7.6%), arthralgia (9.4%) and injection site reactions (11%). CONCLUSION PCSK9mAbs can effectively and safely lower plasma Lp(a) concentrations in patients with elevated Lp(a) in clinical practice; the impact of the fall in Lp(a) on ASCVD outcomes requires further investigation.
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Affiliation(s)
- Anindita Chakraborty
- School of Medicine, Faculty of Health and Medical SciencesUniversity of Western AustraliaPerthAustralia
| | - Jing Pang
- School of Medicine, Faculty of Health and Medical SciencesUniversity of Western AustraliaPerthAustralia
| | - Dick C. Chan
- School of Medicine, Faculty of Health and Medical SciencesUniversity of Western AustraliaPerthAustralia
| | - Wendy Barnett
- Lipid Disorders Clinic, Cardiometabolic Services, Department of CardiologyRoyal Perth HospitalPerthAustralia
| | - Ann Marie Woodward
- Lipid Disorders Clinic, Cardiometabolic Services, Department of CardiologyRoyal Perth HospitalPerthAustralia
| | - Mary Vorster
- Lipid Disorders Clinic, Cardiometabolic Services, Department of CardiologyRoyal Perth HospitalPerthAustralia
| | - Gerald F. Watts
- School of Medicine, Faculty of Health and Medical SciencesUniversity of Western AustraliaPerthAustralia
- Lipid Disorders Clinic, Cardiometabolic Services, Department of CardiologyRoyal Perth HospitalPerthAustralia
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Swerdlow DI, Rider DA, Yavari A, Lindholm MW, Campion GV, Nissen SE. Treatment and prevention of lipoprotein(a)-mediated cardiovascular disease: the emerging potential of RNA interference therapeutics. Cardiovasc Res 2021; 118:1218-1231. [PMID: 33769464 PMCID: PMC8953457 DOI: 10.1093/cvr/cvab100] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 02/19/2021] [Accepted: 03/24/2021] [Indexed: 12/17/2022] Open
Abstract
Lipid- and lipoprotein-modifying therapies have expanded substantially in the last 25 years, resulting in reduction in the incidence of major adverse cardiovascular events. However, no specific lipoprotein(a) [Lp(a)]-targeting therapy has yet been shown to reduce cardiovascular disease risk. Many epidemiological and genetic studies have demonstrated that Lp(a) is an important genetically determined causal risk factor for coronary heart disease, aortic valve disease, stroke, heart failure, and peripheral vascular disease. Accordingly, the need for specific Lp(a)-lowering therapy has become a major public health priority. Approximately 20% of the global population (1.4 billion people) have elevated levels of Lp(a) associated with higher cardiovascular risk, though the threshold for determining ‘high risk’ is debated. Traditional lifestyle approaches to cardiovascular risk reduction are ineffective at lowering Lp(a). To address a lifelong risk factor unmodifiable by non-pharmacological means, Lp(a)-lowering therapy needs to be safe, highly effective, and tolerable for a patient population who will likely require several decades of treatment. N-acetylgalactosamine-conjugated gene silencing therapeutics, such as small interfering RNA (siRNA) and antisense oligonucleotide targeting LPA, are ideally suited for this application, offering a highly tissue- and target transcript-specific approach with the potential for safe and durable Lp(a) lowering with as few as three or four doses per year. In this review, we evaluate the causal role of Lp(a) across the cardiovascular disease spectrum, examine the role of established lipid-modifying therapies in lowering Lp(a), and focus on the anticipated role for siRNA therapeutics in treating and preventing Lp(a)-related disease.
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Affiliation(s)
| | | | - Arash Yavari
- Experimental Therapeutics, Radcliffe, Department of Medicine, University of Oxford, UK
| | | | | | - Steven E Nissen
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Ezhov MV, Tmoyan NA, Afanasieva OI, Afanasieva MI, Pokrovsky SN. Lipoprotein(a) and Cardiovascular Outcomes after Revascularization of Carotid and Lower Limbs Arteries. Biomolecules 2021; 11:biom11020257. [PMID: 33578899 PMCID: PMC7916698 DOI: 10.3390/biom11020257] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 01/27/2021] [Accepted: 02/05/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Despite high-intensity lipid-lowering therapy, there is a residual risk of cardiovascular events that could be associated with lipoprotein(a) (Lp(a)). It has been shown that there is an association between elevated Lp(a) level and cardiovascular outcomes in patients with coronary heart disease. Data about the role of Lp(a) in the development of cardiovascular events after peripheral revascularization are scarce. Purpose: To evaluate the relationship of Lp(a) level with cardiovascular outcomes after revascularization of carotid and lower limbs arteries. Methods: The study included 258 patients (209 men, mean age 67 years) with severe carotid and/or lower extremity artery disease, who underwent successful elective peripheral revascularization. The primary endpoint was the composite of nonfatal myocardial infarction, nonfatal stroke, or cardiovascular death. The secondary endpoint was the composite of primary endpoint and repeated revascularization. Results: For 36-month follow-up, 29 (11%) primary and 128 (50%) secondary endpoints were registered. There was a greater risk of primary (21 (8%) vs. 8 (3%); hazard ratio (HR), 3.0; 95% confidence interval (CI) 1.5–6.3; p < 0.01) and secondary endpoints (83 (32%) vs. 45 (17%), HR, 2.8; 95% CI 2.0–4.0; p < 0.01) in patients with elevated Lp(a) level (≥30 mg/dL) compared to patients with Lp(a) < 30 mg/dL. Multivariable-adjusted Cox regression analysis revealed that Lp(a) was independently associated with the incidence of cardiovascular outcomes. Conclusions: Patients with peripheral artery diseases have a high risk of cardiovascular events. Lp(a) level above 30 mg/dL is significantly and independently associated with cardiovascular events during 3-year follow-up after revascularization of carotid and lower limbs arteries.
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Affiliation(s)
- Marat V. Ezhov
- Laboratory of Lipid Disorders, Department of Atherosclerosis, A.L. Myasnikov Institute of Clinical Cardiology, National Medical Research Center of Cardiology, Ministry of Health of the Russian Federation, 121552 Moscow, Russia
- Correspondence: (M.V.E.); (N.A.T.); Tel.: +7-4-954-146-067 (M.V.E.)
| | - Narek A. Tmoyan
- Laboratory of Lipid Disorders, Department of Atherosclerosis, A.L. Myasnikov Institute of Clinical Cardiology, National Medical Research Center of Cardiology, Ministry of Health of the Russian Federation, 121552 Moscow, Russia
- Correspondence: (M.V.E.); (N.A.T.); Tel.: +7-4-954-146-067 (M.V.E.)
| | - Olga I. Afanasieva
- Laboratory of Atherosclerosis, Institute of Experimental Cardiology, National Medical Research Center of Cardiology, Ministry of Health of the Russian Federation, 121552 Moscow, Russia; (O.I.A.); mi (M.I.A.); (S.N.P.)
| | - Marina I. Afanasieva
- Laboratory of Atherosclerosis, Institute of Experimental Cardiology, National Medical Research Center of Cardiology, Ministry of Health of the Russian Federation, 121552 Moscow, Russia; (O.I.A.); mi (M.I.A.); (S.N.P.)
| | - Sergei N. Pokrovsky
- Laboratory of Atherosclerosis, Institute of Experimental Cardiology, National Medical Research Center of Cardiology, Ministry of Health of the Russian Federation, 121552 Moscow, Russia; (O.I.A.); mi (M.I.A.); (S.N.P.)
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Greco MF, Sirtori CR, Corsini A, Ezhov M, Sampietro T, Ruscica M. Lipoprotein(a) Lowering-From Lipoprotein Apheresis to Antisense Oligonucleotide Approach. J Clin Med 2020; 9:jcm9072103. [PMID: 32635396 PMCID: PMC7408876 DOI: 10.3390/jcm9072103] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 06/24/2020] [Accepted: 07/01/2020] [Indexed: 12/11/2022] Open
Abstract
It is well-known that elevated lipoprotein(a)—Lp(a)—levels are associated with a higher risk of cardiovascular (CV) mortality and all-cause mortality, although a standard pharmacotherapeutic approach is still undefined for patients with high CV risk dependent on hyperlipoproteinemia(a). Combined with high Lp(a) levels, familial hypercholesterolemia (FH) leads to a greater CVD risk. In suspected FH patients, the proportion of cases explained by a rise of Lp(a) levels ranges between 5% and 20%. In the absence of a specific pharmacological approach able to lower Lp(a) to the extent required to achieve CV benefits, the most effective strategy today is lipoprotein apheresis (LA). Although limited, a clear effect on Lp(a) is exerted by PCSK9 antagonists, with apparently different mechanisms when given with statins (raised catabolism) or as monotherapy (reduced production). In the era of RNA-based therapies, a new dawn is represented by the use of antisense oligonucleotides APO(a)Lrx, able to reduce Lp(a) from 35% to over 80%, with generally modest injection site reactions. The improved knowledge of Lp(a) atherogenicity and possible prevention will be of benefit for patients with residual CV risk remaining after the most effective available lipid-lowering agents.
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Affiliation(s)
- Maria Francesca Greco
- Dipartimento di Science Farmacologiche e Biomolecolari, Università degli Studi di Milano, 20133 Milan, Italy; (M.F.G.); (A.C.)
| | - Cesare R. Sirtori
- Dyslipidemia Center, A.S.S.T. Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy;
| | - Alberto Corsini
- Dipartimento di Science Farmacologiche e Biomolecolari, Università degli Studi di Milano, 20133 Milan, Italy; (M.F.G.); (A.C.)
- IRCCS Multimedica, 20099 Milan, Italy
| | - Marat Ezhov
- National Medical Research Center of Cardiology of the Ministry of Health, Moscow, Russia;
| | - Tiziana Sampietro
- U.O. Lipoapheresis and Center for Inherited Dyslipidemias, Fondazione Toscana Gabriele Monasterio, 56126 Pisa, Italy;
| | - Massimiliano Ruscica
- Dipartimento di Science Farmacologiche e Biomolecolari, Università degli Studi di Milano, 20133 Milan, Italy; (M.F.G.); (A.C.)
- Correspondence: ; Tel.: +39-0250318220
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Golledge J, Rowbotham S, Velu R, Quigley F, Jenkins J, Bourke M, Bourke B, Thanigaimani S, Chan DC, Watts GF. Association of Serum Lipoprotein (a) With the Requirement for a Peripheral Artery Operation and the Incidence of Major Adverse Cardiovascular Events in People With Peripheral Artery Disease. J Am Heart Assoc 2020; 9:e015355. [PMID: 32172653 PMCID: PMC7335512 DOI: 10.1161/jaha.119.015355] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 02/04/2020] [Indexed: 12/13/2022]
Abstract
Background The aim of this study was to assess the relationship between serum lipoprotein (a) (Lp[a]) concentration and the requirement for peripheral artery disease (PAD) operations or incidence of major adverse cardiovascular events. Methods and Results A total of 1472 people with PAD presenting with intermittent claudication (n=355), abdominal aortic aneurysm (n=989) or critical limb ischemia (n=128) were prospectively recruited from 4 outpatient clinics in Australia. Lp(a) was measured in serum samples collected at recruitment using an immunoassay. Participants were followed for a median (interquartile range) of 2.4 (0.1-6.1) years to record requirement for any PAD operation, defined to include any open or endovascular PAD intervention (lower limb peripheral revascularization, abdominal aortic aneurysm repair, other aneurysm repair, or carotid artery revascularization). Myocardial infarctions, strokes, and deaths were also recorded. The association of Lp(a) with events was assessed using Cox proportional hazard analysis adjusting for traditional risk factors. Participants with Lp(a) ≥30 mg/dL had a greater requirement for any PAD operation (hazard ratio, 1.20, 95% CI, 1.02-1.41) and lower limb peripheral revascularization alone (hazard ratio 1.33, 95% CI, 1.06-1.66) but no increased risk of major adverse cardiovascular events or all-cause mortality. Lp(a) ≥50 mg/dL and a 40 mg/dL increase in Lp(a) were also associated with an increased risk of lower limb peripheral revascularization alone but not with other outcomes. Conclusions In participants with PAD referred for hospital management those with high Lp(a) had greater requirement for lower limb peripheral revascularization but Lp(a) was not consistently associated with other clinical events.
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Affiliation(s)
- Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular DiseaseCollege of Medicine and DentistryJames Cook UniversityTownsvilleQueenslandAustralia
- The Department of Vascular and Endovascular SurgeryTownsville University HospitalTownsvilleQueenslandAustralia
- The Australian Institute of Tropical Health and MedicineJames Cook UniversityTownsvilleQueenslandAustralia
| | - Sophie Rowbotham
- Queensland Research Centre for Peripheral Vascular DiseaseCollege of Medicine and DentistryJames Cook UniversityTownsvilleQueenslandAustralia
- The University of QueenslandUQ Centre for Clinical ResearchHerstonQueenslandAustralia
| | - Ramesh Velu
- The Department of Vascular and Endovascular SurgeryTownsville University HospitalTownsvilleQueenslandAustralia
| | | | - Jason Jenkins
- Department of Vascular SurgeryThe Royal Brisbane and Women's HospitalBrisbaneQueenslandAustralia
| | - Michael Bourke
- Gosford Vascular ServicesGosfordNew South WalesAustralia
| | - Bernie Bourke
- Gosford Vascular ServicesGosfordNew South WalesAustralia
| | - Shivshankar Thanigaimani
- Queensland Research Centre for Peripheral Vascular DiseaseCollege of Medicine and DentistryJames Cook UniversityTownsvilleQueenslandAustralia
| | - Dick C. Chan
- School of MedicineFaculty of Health and Medical SciencesUniversity of Western AustraliaPerthAustralia
| | - Gerald F. Watts
- School of MedicineFaculty of Health and Medical SciencesUniversity of Western AustraliaPerthAustralia
- Lipid Disorders ClinicDepartment of CardiologyRoyal Perth HospitalPerthAustralia
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