A blood test to assess cardiovascular risk that every patient should know (but too often doesn’t)

When it comes to cardiovascular health and prevention, most of us are aware of routine checks for cholesterol, blood pressure, and blood sugar levels. However, there’s another critical test that often goes unchecked: lipoprotein(a), or Lp(a). Despite its impact on heart health, Lp(a) testing isn’t typically included in standard lab panels or even in comprehensive “Executive Physicals.” In fact less than 1% of the American population has ever had their lipoprotein A checked, despite elevated levels being seen in 1 out of every 5 individuals. Here’s why knowing your Lp(a) level matters, what you can do if it’s elevated, and how groundbreaking research is paving the way for new treatments.

What is Lipoprotein(a), and Why is It Often Overlooked?

Lipoprotein(a) is a type of low-density lipoprotein (LDL) particle that has an additional protein component called apolipoprotein(a). This structure makes it more likely to form plaques in arteries (think of it as “sticky” cholesterol), which can lead to cardiovascular disease (CVD). Elevated Lp(a) is strongly associated with an increased risk of heart attacks, strokes, and aortic valve disease. Remarkably, high Lp(a) levels are also an independent risk factor, meaning they contribute to cardiovascular risk even if other markers like cholesterol or blood pressure are normal.

So, why is Lp(a) testing not standard? In short, awareness about its importance is still growing, and there has historically been a lack of effective treatments to lower it. Consequently, many healthcare providers and labs do not routinely include it in annual bloodwork or even high-level executive health assessments. However, recent guideline changes, such as those from the European Society of Cardiology, recommend at least a one-time Lp(a) test for all adults to identify those at high cardiovascular risk.

What Does an Elevated Lp(a) Level Mean and What Can Be Done For It?

If your Lp(a) level is high, it signifies an increased cardiovascular risk independent of traditional factors. Elevated Lp(a) levels can increase the likelihood of plaque formation in the arteries, which may lead to serious events like heart attacks or strokes. The importance of having this checked is especially pronounced for those with a family history of premature heart disease, as Lp(a) is primarily inherited.

An elevated Lp(a) level can be a red flag, signaling that you may need to take extra precautions to protect your heart health. Here are some steps you can take:

1. Intensify Monitoring and Testing: Regular cardiovascular assessments, such as advanced lipid panels and imaging for arterial plaque and cardiac valves, can help track your risk over time.

2. Aggressively Manage Other Risk Factors: Since Lp(a) itself is not easily modifiable, controlling other risk factors like LDL cholesterol, blood pressure, and inflammation becomes crucial. Maintaining a heart-healthy lifestyle, including a balanced diet, regular exercise, and stress management, also supports overall cardiovascular health.

3. Consider Family Screening: Elevated Lp(a) levels are genetically determined, so your family members may also be at risk. They should consider getting tested, especially if there’s a family history of early cardiovascular disease.

4. PCSK9 Inhibitors: These medications, originally developed to lower LDL cholesterol, have shown some promise in moderately reducing Lp(a) levels. The Fourier & Odyssey Outcomes trials showed about a 15-30% reduction in lp(a).

5. Apheresis: This procedure, similar to dialysis, can filter Lp(a) out of the bloodstream. Apheresis is typically used in patients with extremely high Lp(a) levels who have already experienced cardiovascular events and are at significant risk.

6. Estrogen: typically about 15% reduction in lipoprotein (a) levels

*Statins may raise lp(a) levels slightly and ezetemibe have no effect on lipoprotein (a). Diet has no effect on lp(a) levels.

New Treatments in the Pipeline: A Hopeful Future for Lp(a) Management

The strong link between Lp(a) and cardiovascular risk has fueled a surge in research to develop effective treatments. Several promising therapies are now in clinical trials:

1. Gene-Silencing Therapies/Antisense Oligonucleotides: One of the most exciting areas of research focuses on gene-silencing therapies that target the gene responsible for producing apolipoprotein(a). These drugs work by "silencing" the LPA gene, thereby reducing Lp(a) production. In clinical trials, these therapies have shown reductions in Lp(a) levels by up to 90%, a promising step for those at risk.

   A. Lepodisiran (Eli Lilly), zerlasiran (Silence Therapeutics), and pelacarsen (Novartis/Ionis Pharmaceuticals)- all currently in Phase II or III. Pelacarsen phase III data expected in 2025 from the Horizon trial

2. RNA-Based Therapies: Small interfering RNA (siRNA) treatments are also in development. These drugs target Lp(a) production at the genetic level and are showing promising results in early-stage trials.

   A. Olpasiran (Amgen)

Final Thoughts

If you’re serious about proactive health and preventative medicine, knowing your lp(a) level is imperative. All of our members at Vitality by AWI are screened for their lp(a) at their initial evaluation, along with many other cardiovascular and health markers. Thanks to an increased awareness of its importance, the future for patient’s with an elevated lp(a) has become increasingly hopeful. The first step, however, is simply knowing your risk.