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Kelsey MD, Mulder H, Chiswell K, Lampron ZM, Nilles E, Kulinski JP, Joshi PH, Jones WS, Chamberlain AM, Leucker TM, Hwang W, Milks MW, Paranjape A, Obeid JS, Linton MF, Kent ST, Peterson ED, O'Brien EC, Pagidipati NJ. Contemporary patterns of lipoprotein(a) testing and associated clinical care and outcomes. Am J Prev Cardiol 2023; 14:100478. [PMID: 37025553 PMCID: PMC10070377 DOI: 10.1016/j.ajpc.2023.100478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 02/13/2023] [Accepted: 02/25/2023] [Indexed: 03/06/2023] Open
Abstract
Objective Elevated lipoprotein(a) [Lp(a)] is associated with atherosclerotic cardiovascular disease, yet little is known about Lp(a) testing patterns in real-world practice. The objective of this analysis was to determine how Lp(a) testing is used in clinical practice in comparison with low density lipoprotein cholesterol (LDL-C) testing alone, and to determine whether elevated Lp(a) level is associated with subsequent initiation of lipid-lowering therapy (LLT) and incident cardiovascular (CV) events. Methods This is an observational cohort study, based on lab tests administered between Jan 1, 2015 and Dec 31, 2019. We used electronic health record (EHR) data from 11 United States health systems participating in the National Patient-Centered Clinical Research Network (PCORnet). We created two cohorts for comparison: 1) the Lp(a) cohort, of adults with an Lp(a) test and 2) the LDL-C cohort, of 4:1 date- and site-matched adults with an LDL-C test, but no Lp(a) test. The primary exposure was the presence of an Lp(a) or LDL-C test result. In the Lp(a) cohort, we used logistic regression to assess the relationship between Lp(a) results in mass units (< 50, 50-100, and > 100mg/dL) and molar units (<125, 125-250, > 250nmol/L) and initiation of LLT within 3 months. We used multivariable adjusted Cox proportional hazards regression to evaluate these Lp(a) levels and time to composite CV hospitalization, including hospitalization for myocardial infarction, revascularization and ischemic stroke. Results Overall, 20,551 patients had Lp(a) test results and 2,584,773 patients had LDL-C test results (82,204 included in the matched LDL-C cohort). Compared with the LDL-C cohort, the Lp(a) cohort more frequently had prevalent ASCVD (24.3% vs. 8.5%) and multiple prior CV events (8.6% vs. 2.6%). Elevated Lp(a) was associated with greater odds of subsequent LLT initiation. Elevated Lp(a) reported in mass units was also associated with subsequent composite CV hospitalization [aHR (95% CI): Lp(a) 50-100mg/dL 1.25 (1.02-1.53), p<0.03, Lp(a) > 100mg/dL 1.23 (1.08-1.40), p<0.01]. Conclusion Lp(a) testing is relatively infrequent in health systems across the U.S. As new therapies for Lp(a) emerge, improved patient and provider education is needed to increase awareness of the utility of this risk marker.
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Affiliation(s)
- Michelle D. Kelsey
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | | | | | | | - Ester Nilles
- Duke Clinical Research Institute, Durham, NC, USA
| | - Jacquelyn P. Kulinski
- Department of Medicine, Division of Cardiology, Medical College of Wisconsin, Milwaukee, USA
| | - Parag H. Joshi
- Department of Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - W. Schuyler Jones
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Alanna M. Chamberlain
- Department of Quantitative Health Sciences Research, Mayo Clinic, Rochester, MN, USA
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Thorsten M. Leucker
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, MD, USA
| | - Wenke Hwang
- Department of Public Health Sciences, Penn State Hershey Medical Center, The Pennsylvania State University, PA, USA
| | - M. Wesley Milks
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Anuradha Paranjape
- Department of Medicine, Temple University Lewis Katz School of Medicine, Philadelphia, PA, USA
| | - Jihad S. Obeid
- Division of Biomedical Informatics, Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - MacRae F. Linton
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Shia T. Kent
- Center for Observational Research, Amgen Inc., Thousand Oaks, CA, USA
| | - Eric D. Peterson
- Department of Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Neha J. Pagidipati
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
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