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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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Kamstrup PR, Neely RDG, Nissen S, Landmesser U, Haghikia A, Costa-Scharplatz M, Abbas C, Nordestgaard BG. Lipoprotein(a) and cardiovascular disease: sifting the evidence to guide future research. Eur J Prev Cardiol 2024; 31:903-914. [PMID: 38253342 DOI: 10.1093/eurjpc/zwae032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 12/29/2023] [Accepted: 01/03/2024] [Indexed: 01/24/2024]
Abstract
Lipoprotein(a) (Lp(a)) is a genetically determined causal risk factor for cardiovascular disease including coronary heart disease, peripheral arterial disease, ischaemic stroke, and calcific aortic valve stenosis. Clinical trials of specific and potent Lp(a)-lowering drugs are currently underway. However, in clinical practice, widespread assessment of Lp(a) is still lacking despite several guideline recommendations to measure Lp(a) at least once in a lifetime in all adults to identify those at high or very high risk due to elevated levels. The present review provides an overview of key findings from observational and genetic Lp(a) studies, highlights the main challenges in observational Lp(a) studies, and proposes a minimum set of requirements to enhance the quality and harmonize the collection of Lp(a)-related data. Adherence to the recommendations set forth in the present manuscript is intended to enhance the quality of future observational Lp(a) studies, to better define thresholds for increased risk, and to better inform clinical trial design. The recommendations can also potentially assist in the interpretation and generalization of clinical trial findings, to improve care of patients with elevated Lp(a) and optimize treatment and prevention of cardiovascular disease.
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Affiliation(s)
- Pia R Kamstrup
- Department of Clinical Biochemistry, Copenhagen University Hospital-Herlev and Gentofte, Borgmester Ib Juuls Vej 73, 2730 Herlev, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - R Dermot G Neely
- Academic Health Science Network North East and North Cumbria (AHSN), Room 2.13, Biomedical Research Building, The Campus for Ageing and Vitality, Nun's Moor Road, Newcastle, NE4 5PL
| | - Steven Nissen
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Ulf Landmesser
- Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine, Hindenburgdamm 30, Berlin 12203, Germany
- DZHK (German Centre for Cardiovascular Research) partner Site Berlin, Berlin 12203, Germany
- Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, Berlin 10117, Germany
- Berlin Institute of Health (BIH), Anna-Louisa-Karsch-Str. 2, Berlin 10178, Germany
| | - Arash Haghikia
- Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine, Hindenburgdamm 30, Berlin 12203, Germany
- DZHK (German Centre for Cardiovascular Research) partner Site Berlin, Berlin 12203, Germany
- Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, Berlin 10117, Germany
- Berlin Institute of Health (BIH), Anna-Louisa-Karsch-Str. 2, Berlin 10178, Germany
| | | | - Cheryl Abbas
- Novartis Pharmaceuticals Corporation, US Medical, East Hanover, NJ, USA
| | - Børge G Nordestgaard
- Department of Clinical Biochemistry, Copenhagen University Hospital-Herlev and Gentofte, Borgmester Ib Juuls Vej 73, 2730 Herlev, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Ward NC, Watts GF, Bishop W, Colquhoun D, Hamilton-Craig C, Hare DL, Kangaharan N, Kostner KM, Kritharides L, O'Brien R, Mori TA, Nestel PJ, Nicholls SJ, Psaltis PJ, Raffoul N, White HD, Sullivan DR. Australian Atherosclerosis Society Position Statement on Lipoprotein(a): Clinical and Implementation Recommendations. Heart Lung Circ 2023; 32:287-296. [PMID: 36707360 DOI: 10.1016/j.hlc.2022.11.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 11/09/2022] [Indexed: 01/26/2023]
Abstract
This position statement provides guidance to cardiologists and related specialists on the management of adult patients with elevated lipoprotein(a) [Lp(a)]. Elevated Lp(a) is an independent and causal risk factor for atherosclerotic cardiovascular disease (ASCVD) and calcific aortic valve disease (CAVD). While circulating Lp(a) levels are largely determined by ancestry, they are also influenced by ethnicity, hormones, renal function, and acute inflammatory events, such that measurement should be done after accounting for these factors. Further, circulating Lp(a) concentrations should be estimated using an apo(a)-isoform independent assay that employs appropriate calibrators and reports the results in molar units (nmol/L). Selective screening strategies of high-risk patients are recommended, but universal screening of the population is currently not advised. Testing for elevated Lp(a) is recommended in all patients with premature ASCVD and those considered to be at intermediate-to-high risk of ASCVD. Elevated Lp(a) should be employed to assess and stratify risk and to enable a decision on initiation or intensification of preventative treatments, such as cholesterol lowering therapy. In adult patients with elevated Lp(a) at intermediate-to-high risk of ASCVD, absolute risk should be reduced by addressing all modifiable behavioural, lifestyle, psychosocial and clinical risk factors, including maximising cholesterol-lowering with statin and ezetimibe and, where appropriate, PCSK9 inhibitors. Apheresis should be considered in patients with progressive ASCVD. New ribonucleic acid (RNA)-based therapies which directly lower Lp(a) are undergoing clinical trials.
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Affiliation(s)
- Natalie C Ward
- Dobney Hypertension Centre, Medical School, University of Western Australia, Perth, WA, Australia.
| | - Gerald F Watts
- Medical School, University of Western Australia, Perth, WA, Australia; Lipid Disorders Clinic, Department of Cardiology, Royal Perth Hospital, Perth, WA, Australia
| | | | - David Colquhoun
- Faculty of Medicine, Wesley Medical Centre, Brisbane, Qld, Australia; Faculty of Medicine, Medical School, University of Queensland, Brisbane, Qld, Australia
| | - Christian Hamilton-Craig
- Faculty of Medicine, University of Queensland, Brisbane, Qld, Australia; Faculty of Medicine, Dentistry and Health, School of Medicine, Griffith University, Sunshine Coast, Qld, Australia
| | - David L Hare
- Faculty of Medicine, Dentistry & Health Sciences, University of Melbourne, Melbourne, Vic, Australia and Department of Cardiology, Austin Hospital, Heidelberg, Vic, Australia
| | | | - Karam M Kostner
- Department of Cardiology, Mater Hospital, Brisbane, Qld, Australia; Medical School, University of Queensland, Brisbane, Qld, Australia
| | - Leonard Kritharides
- Sydney Medical School, Faculty of Medicine, University of Sydney, Sydney, NSW, Australia and Department of Cardiology, Concord Repatriation General Hospital, Sydney Local Health District, Sydney, NSW, Australia
| | - Richard O'Brien
- Austin Clinical School, University of Melbourne, Melbourne, Vic, Australia and Director of Lipid Services, Austin Health, Melbourne, Vic, Australia
| | - Trevor A Mori
- Medical School, University of Western Australia, Perth, WA, Australia
| | - Paul J Nestel
- Baker Heart & Diabetes Institute, Melbourne, Vic, Australia
| | - Stephen J Nicholls
- Monash Cardiovascular Research Centre, Victorian Heart Institute, Monash University, Melbourne, Vic, Australia
| | - Peter J Psaltis
- Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia; Vascular Research Centre, Lifelong Health Theme, South Australian Health & Medical Research Institute, Adelaide, SA, Australia; and Department of Cardiology, Central Adelaide Local Health Network, Adelaide, SA, Australia
| | | | - Harvey D White
- Te Whatu Ora-Health New Zealand, Green Lane Cardiovascular Service, Te Toka Tumai, Auckland, New Zealand
| | - David R Sullivan
- Medical School, University of Sydney, Sydney, NSW, Australia; Charles Perkins Centre, University of Sydney, Sydney, NSW, Australia, and Department of Biochemistry, Royal Prince Alfred Hospital, Sydney, NSW, Australia
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Causes, Angiographic Characteristics, and Management of Premature Myocardial Infarction: JACC State-of-the-Art Review. J Am Coll Cardiol 2022; 79:2431-2449. [PMID: 35710195 DOI: 10.1016/j.jacc.2022.04.015] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 03/31/2022] [Accepted: 04/13/2022] [Indexed: 12/13/2022]
Abstract
Among patients presenting with acute myocardial infarction (AMI), the proportion of young individuals has increased in recent years. Although coronary atherosclerosis is less extensive in young patients with AMI, with higher prevalence of single-vessel disease and rare left main involvement, the long-term prognosis is not benign. Young patients with AMI with obstructive coronary artery disease have similar risk factors as older patients except for higher prevalence of smoking, lipid disorders, and family history of premature coronary artery disease, and lower prevalence of diabetes mellitus and hypertension. Smoking cessation is by far the most effective secondary preventive measure. Myocardial infarction with nonobstructive coronary arteries is a relatively common clinical entity (10%-20%) among young patients with AMI, with intravascular and cardiac magnetic resonance imaging being key for diagnosis and potentially treatment. Spontaneous coronary artery dissection is a frequent pathogenetic mechanism of AMI among young women, requiring a high degree of suspicion, especially in the peripartum period.
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Rizk T, Blankstein R. Not All Heart Attacks are Created Equal: Thinking Differently About Acute Myocardial Infarction in the Young. Methodist Debakey Cardiovasc J 2021; 17:60-67. [PMID: 34824682 PMCID: PMC8588727 DOI: 10.14797/mdcvj.345] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 07/13/2021] [Indexed: 11/24/2022] Open
Abstract
Cardiovascular disease, particularly myocardial infarction, remains a major cause of morbidity and mortality among young individuals. Although myocardial infarctions have declined significantly in the general population, this decline has not been uniformly observed in younger cohorts. Young adults often have different risk factors, including a higher burden of tobacco use and substance abuse, and they are less likely to be treated with preventive therapies since they are often categorized as having low risk. This review examines the existing literature on myocardial infarction in young patients, with a focus on risk factors, therapeutic challenges, and opportunities for prevention.
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Affiliation(s)
- Theresa Rizk
- Duke University School of Medicine, Durham, North Carolina, US.,Brigham and Women's Hospital, Brookline, Massachusetts, US
| | - Ron Blankstein
- Brigham and Women's Hospital, Brookline, Massachusetts, US.,Harvard Medical School, Cambridge, Massachusetts, US
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