Existing and emerging strategies to lower Lipoprotein(a)

What's next for lipoprotein(a)? A National Lipid Association report from an Expert Panel Discussion

This is an exciting time in the lipoprotein(a) [Lp(a)] field. Attention to this important lipoprotein and potent cardiovascular risk marker is transitioning from the purview of the specialist to that of the general practitioner. Its clinical adoption as an important test is increasing in momentum. There is evidence that Lp(a) contributes to the pathology of atherothrombotic disease, aortic valve stenosis, and childhood ischemic strokes. Three large, Phase 3, randomized, cardiovascular outcomes trials in which Lp(a) is specifically and substantially lowered by mRNA-directed therapies in secondary prevention settings are in progress and will start to report results as early as 2025. Regardless of outcomes, there remain many unanswered questions about Lp(a), ranging from fundamental unknowns about Lp(a) biology, to the complexity of its measurement, optimal screening strategies, and clinical management in individuals with high Lp(a) levels both with and without overt cardiovascular disease. Accordingly, The National Lipid Association (NLA) convened an Expert Discussion involving clinicians and fundamental researchers to identify knowledge gaps in our understanding of Lp(a) biology and pathogenicity and to discuss approaches in the management of elevated Lp(a) in different clinical settings.

Lipoprotein(a) and cardiovascular disease

Elevated plasma levels of lipoprotein(a) (Lp(a)) are a prevalent, independent, and causal risk factor for atherosclerotic cardiovascular disease and calcific aortic valve disease. Lp(a) consists of a lipoprotein particle resembling low density lipoprotein and the covalently-attached glycoprotein apolipoprotein(a) (apo(a)). Novel therapeutics that specifically and potently lower Lp(a) levels are currently in advanced stages of clinical development, including in large, phase 3 cardiovascular outcomes trials. However, fundamental unanswered questions remain concerning some key aspects of Lp(a) biosynthesis and catabolism as well as the true pathogenic mechanisms of the particle. In this review, we describe the salient biochemical features of Lp(a) and apo(a) and how they underlie the disease-causing potential of Lp(a), the factors that determine plasma Lp(a) concentrations, and the mechanism of action of Lp(a)-lowering drugs.

Elevated lipoprotein(a) levels: A crucial determinant of cardiovascular disease risk and target for emerging therapies

Cardiovascular disease (CVD) remains a significant global health challenge despite advancements in prevention and treatment. Elevated Lipoprotein(a) [Lp(a)] levels have emerged as a crucial risk factor for CVD and aortic stenosis, affecting approximately 20 of the global population. Research over the last decade has established Lp(a) as an independent genetic contributor to CVD and aortic stenosis, beginning with Kare Berg's discovery in 1963. This has led to extensive exploration of its molecular structure and pathogenic roles. Despite the unknown physiological function of Lp(a), studies have shed light on its metabolism, genetics, and involvement in atherosclerosis, inflammation, and thrombosis. Epidemiological evidence highlights the link between high Lp(a) levels and increased cardiovascular morbidity and mortality. Newly emerging therapies, including pelacarsen, zerlasiran, olpasiran, muvalaplin, and lepodisiran, show promise in significantly lowering Lp(a) levels, potentially transforming the management of cardiovascular disease. However, further research is essential to assess these novel therapies' long-term efficacy and safety, heralding a new era in cardiovascular disease prevention and treatment and providing hope for at-risk patients.

Consensus on lipoprotein(a) of the Spanish Society of Arteriosclerosis. Literature review and recommendations for clinical practice

The irruption of lipoprotein(a) (Lp(a)) in the study of cardiovascular risk factors is perhaps, together with the discovery and use of proprotein convertase subtilisin/kexin type 9 (iPCSK9) inhibitor drugs, the greatest novelty in the field for decades. Lp(a) concentration (especially very high levels) has an undeniable association with certain cardiovascular complications, such as atherosclerotic vascular disease (AVD) and aortic stenosis. However, there are several current limitations to both establishing epidemiological associations and specific pharmacological treatment. Firstly, the measurement of Lp(a) is highly dependent on the test used, mainly because of the characteristics of the molecule. Secondly, Lp(a) concentration is more than 80% genetically determined, so that, unlike other cardiovascular risk factors, it cannot be regulated by lifestyle changes. Finally, although there are many promising clinical trials with specific drugs to reduce Lp(a), currently only iPCSK9 (limited for use because of its cost) significantly reduces Lp(a). However, and in line with other scientific societies, the SEA considers that, with the aim of increasing knowledge about the contribution of Lp(a) to cardiovascular risk, it is relevant to produce a document containing the current status of the subject, recommendations for the control of global cardiovascular risk in people with elevated Lp(a) and recommendations on the therapeutic approach to patients with elevated Lp(a).

High lipoprotein(a): Actionable strategies for risk assessment and mitigation

High levels of lipoprotein(a) [Lp(a)] are causal for atherosclerotic cardiovascular disease (ASCVD). Lp(a) is the most prevalent inherited dyslipidemia and strongest genetic ASCVD risk factor. This risk persists in the presence of at target, guideline-recommended, LDL-C levels and adherence to lifestyle modifications. Epidemiological and genetic evidence supporting its causal role in ASCVD and calcific aortic stenosis continues to accumulate, although various facets regarding Lp(a) biology (genetics, pathophysiology, and expression across race/ethnic groups) are not yet fully understood. The evolving nature of clinical guidelines and consensus statements recommending universal measurements of Lp(a) and the scientific data supporting its role in multiple disease states reinforce the clinical merit to start population screening for Lp(a) now. There is a current gap in the implementation of recommendations for primary and secondary cardiovascular disease (CVD) prevention in those with high Lp(a), in part due to a lack of protocols for management strategies. Importantly, targeted apolipoprotein(a) [apo(a)]-lowering therapies that reduce Lp(a) levels in patients with high Lp(a) are in phase 3 clinical development. This review focuses on the identification and clinical management of patients with high Lp(a). Specifically, we highlight the clinical value of measuring Lp(a) and its use in determining Lp(a)-associated CVD risk by providing actionable guidance, based on scientific knowledge, that can be utilized now to mitigate risk caused by high Lp(a).

Lipoprotein(a): from Causality to Treatment

PURPOSE OF REVIEW

This paper reviews the evidence why lipoprotein(a) (Lp(a)) is a causal risk factor for cardiovascular disease and how high Lp(a) concentrations should be managed now and with an outlook to the future.

REVIEW FINDINGS

No optimal and widely available animal models exist to study the causality of the association between Lp(a) and cardiovascular disease. This has been a major handicap for the entire field. However, genetic studies turned the page. Already in the early 1990s, the principle of Mendelian randomization studies was applied for the first time ever (even if they were not named so at that time). Genetic variants of the LPA gene such as the apolipoprotein(a) isoform size, the number and sum of kringle IV repeats and later single nucleotide polymorphisms are strongly associated with life-long exposure to high Lp(a) concentrations as well as cardiovascular outcomes. This evidence provided a basis for the development of specific Lp(a)-lowering drugs that are currently in clinical testing phase. Lp(a) is one of the most important genetically determined risk factors for cardiovascular disease. With the specific Lp(a)-lowering therapies, we might get tools to fight this common risk factor in case the outcome trials will be positive.

The 10 essential questions regarding lipoprotein(a)

PURPOSE OF REVIEW

Lp(a) is one of the most atherogenic lipoproteins, and significant progress has been made to understand its pathophysiology over the last 20 years. There are now selective therapies in late-stage clinical trials to lower Lp(a). Yet there are many outstanding questions about Lp(a). This review outlines 10 of the most burning questions and tries to answer some of them.

RECENT FINDINGS

Antisense oligonucleotide (ASO) treatment is currently the most advanced therapy to lower plasma Lp(a) by 60-80%. There are, however, also two small molecule medications in early stage of development with similar efficacy.

SUMMARY

This review aims to answer important preclinical and clinical questions about the metabolism and physiological role of Lp(a) and also outlines possible therapeutic approaches with nutraceuticals, currently available lipid-lowering therapies and new medications. In addition, ways are illustrated to use Lp(a) as a marker to better predict cardiovascular risk.

Association of Renal Function and Statin Therapy with Lipoprotein(a) in Patients with Type 2 Diabetes

AIM

A high level of serum lipoprotein(a) [Lp(a)] is associated with kidney disease development in patients with type 2 diabetes (T2DM). Recent studies have suggested that statins may affect serum levels of Lp(a). However, the statin effect is not well-defined in patients with T2DM with kidney dysfunction. This retrospective study aimed to investigate the relevance of kidney dysfunction and statin therapy to Lp(a) in patients with T2DM.

METHODS

Japanese patients with T2DM (n=149, 96 men and 53 women) were divided into two groups: statin users (n=79) and non-statin users (n=70). Multiple logistic regression analyses were performed with Lp(a) as the objective variable and estimated glomerular filtration rate (eGFR), hemoglobin A1c, age, gender, and body mass index as the explanatory variables.

RESULTS

Lp(a) serum levels were higher in statin users than in non-statin users (P=0.022). Multivariate regression analysis results showed an inverse correlation of eGFR to log Lp(a) in all patients (P=0.009) and in non-statin users (P=0.025), but not in statin users. In a multiple logistic regression analysis for median Lp(a), there was an inverse association between eGFR and Lp(a) level (odds ratio, 0.965; 95% confidence interval, 0.935-0.997; P=0.030) in non-statin users as well as in all participants, but not in statin users.

CONCLUSIONS

The present study suggests that a high Lp(a) level in patients with T2DM, except in statin users, is significantly associated with decreased eGFR, indicating that the increased Lp(a) levels under statin therapy might diminish the relationship between Lp(a) and eGFR.

Healthy lifestyle, lipoprotein (a) levels and the risk of coronary artery disease

BACKGROUND

Lipoprotein (a) [Lp(a)] is associated with coronary artery disease (CAD). However, the role of healthy lifestyle against the risk of CAD with consideration of high Lp(a) levels remains unclear.

METHODS

This study examined 4512 participants who underwent serum Lp(a) level assessment at Kanazawa University Hospital from 2008 to March 2016. Their lifestyle habits were examined based on four questionnaires regarding dietary pattern, exercise habits, smoking status and body weight. Logistic regression analyses were performed to identify the association between healthy lifestyle and CAD independent of Lp(a) levels.

RESULTS

The Lp(a) levels were significantly associated with CAD (odds ratio [OR]: 1.12, 95% confidence interval [CI]: 1.08-1.17, p = 1.3 × 10-7 per 10 mg/dL). Under these circumstances, the lifestyle risk score was also significantly associated with CAD (OR: 1.24, 95% CI: 1.12-1.36, p = 2.4 × 10-8 ). Compared with patients with a favourable lifestyle who have Lp(a) levels of <30 mg/dL, those with an intermediate or unfavourable lifestyle were at higher risk for CAD (OR: 1.11, 95% CI: 1.02-1.20, p = 0.003 and OR: 1.40, 95% CI: 1.16-1.54, p = 3.6 × 10-5 , respectively). Further, patients with a favourable, intermediate or unfavourable lifestyle who have Lp(a) levels of ≥30 mg/dL were at high risk for CAD (OR: 1.21, 95% CI: 1.08-1.34, p = 0.0014; OR: 1.31, 95% CI: 1.14-1.48, p = 1.2 × 10-4 ; and OR: 1.81, 95% CI: 1.44-2.18, p = 2.2 × 10-7 , respectively).

CONCLUSIONS

Healthy lifestyle was associated with a lower risk of CAD regardless of Lp(a) levels.

Association Between Free Fatty Acids and Cardiometabolic Risk in Coronary Artery Disease: Results From the PROMISE Study

CONTEXT

The association between free fatty acids (FFAs) and unfavorable clinical outcomes has been reported in the general population. However, evidence in the secondary prevention population is relatively scarce.

OBJECTIVE

We aimed to examine the relationship between FFA and cardiovascular risk in patients with coronary artery disease (CAD).

METHODS

This study was based on a multicenter cohort of patients with CAD enrolled from January 2015 to May 2019. The primary outcome was all-cause death. Secondary outcomes included cardiac death and major adverse cardiovascular events (MACE), a composite of death, myocardial infarction, and unplanned revascularization.

RESULTS

During a follow-up of 2 years, there were 468 (3.0%) all-cause deaths, 335 (2.1%) cardiac deaths, and 1279 (8.1%) MACE. Elevated FFA levels were independently associated with increased risks of all-cause death, cardiac death, and MACE (all P < .05). Moreover, When FFA were combined with an original model derived from the Cox regression, there were significant improvements in discrimination and reclassification for prediction of all-cause death (net reclassification improvement [NRI] 0.245, P < .001; integrated discrimination improvement [IDI] 0.004, P = .004), cardiac death (NRI 0.269, P < .001; IDI 0.003, P = .006), and MACE (NRI 0.268, P < .001; IDI 0.004, P < .001). Notably, when stratified by age, we found that the association between FFA with MACE risk appeared to be stronger in patients aged ≥60 years compared with those aged <60 years.

CONCLUSION

In patients with CAD, FFAs are associated with all-cause death, cardiac death, and MACE. Combined evaluation of FFAs with other traditional risk factors could help identify high-risk individuals who may require closer monitoring and aggressive treatment.

Stratification in Heterozygous Familial Hypercholesterolemia: Imaging, Biomarkers, and Genetic Testing

PURPOSE OF REVIEW

Heterozygous familial hypercholesterolemia (HeFH) is the most common monogenic autosomal dominant disorder. However, the condition is often underdiagnosed and undertreated. The objective of this review is to provide an update on the risk stratification in patients with HeFH, incorporating new cardiovascular imaging techniques, various biomarkers, and genetic studies.

RECENT FINDINGS

The diagnosis of HeFH places patients in a high cardiovascular risk category due to the increased incidence of premature atherosclerotic cardiovascular disease. However, the level of risk varies significantly among different individuals with HeFH. Achieving an optimal stratification of cardiovascular risk is crucial for establishing appropriate and accurate treatment and management strategies. Different new tools such as risk scores have emerged in recent years, aiding physicians in assessing the risk stratification for HeFH using imaging, biomarkers, and genetics. This review emphasizes that not all patients with HeFH face the same cardiovascular risk. By utilizing different assessment tools, we can identify those who require more intensive monitoring, follow-up, and treatment.

Exploring PCSK9 Genetic Impact on Lipoprotein(a) via Dual Approaches: Association and Mendelian Randomization

Previous investigations have suggested an association between the PCSK9 common polymorphism E670G and Lipoprotein(a) (Lp(a)) levels, as well as a link between plasma PCSK9 levels and Lp(a) concentrations. However, the causal relationship between plasma PCSK9 and Lp(a) levels remains uncertain. In this study, we explored the association between PCSK9 E670G polymorphism and Lp(a) levels in 614 healthy Taiwanese individuals. Employing a two-sample Mendelian randomization (MR) analysis using openly accessible PCSK9 and Lp(a) summary statistics from the genome-wide association studies (GWAS) and UK Biobank, we aimed to determine if a causal link exists between plasma PCSK9 levels and Lp(a) concentrations. Our findings reveal that the E670G G allele is independently associated with a decreased likelihood of developing elevated Lp(a) levels. This association persists even after adjusting for common cardiovascular risk factors and irrespective of lipid profile variations. The MR analysis, utilizing six PCSK9 GWAS-associated variants as instrumental variables to predict plasma PCSK9 levels, provides compelling evidence of a causal relationship between plasma PCSK9 levels and Lp(a) concentration. In conclusion, our study not only replicates the association between the PCSK9 E670G polymorphism and Lp(a) levels but also confirms a causative relationship between PCSK9 levels and Lp(a) concentrations through MR analysis.

Lipoprotein(a) in patients with breast cancer after chemotherapy: exploring potential strategies for cardioprotection

Developments in neoadjuvant and adjuvant chemotherapy (CHT) have led to an increase in the number of breast cancer survivors. The determination of an appropriate follow-up for these patients is of increasing importance. Deaths due to cardiovascular disease (CVD) are an important part of mortality in patients with breast cancer.This review suggests that chemotherapeutic agents may influence lipoprotein(a) (Lp(a)) concentrations in breast cancer survivors after CHT based on many convincing evidence from epidemiologic and observational researches. Usually, the higher the Lp(a) concentration, the higher the median risk of developing CVD. However, more clinical trial results are needed in the future to provide clear evidence of a possible causal relationship. This review also discuss the existing and emerging therapies for lowering Lp(a) concentrations in the clinical setting. Hormone replacement therapy, statins, proprotein convertase subtilisin/kexin-type 9 (PCSK9) inhibitors, Antisense oligonucleotides, small interfering RNA, etc. may reduce circulating Lp(a) or decrease the incidence of CVD.

Daring to dream: Targeting lipoprotein(a) as a causal and risk-enhancing factor

Lipoprotein(a) [Lp(a)], a distinct lipoprotein class, has become a major focus for cardiovascular research. This review is written in light of the recent guideline and consensus statements on Lp(a) and focuses on 1) the causal association between Lp(a) and cardiovascular outcomes, 2) the potential mechanisms by which elevated Lp(a) contributes to cardiovascular diseases, 3) the metabolic insights on the production and clearance of Lp(a) and 4) the current and future therapeutic approaches to lower Lp(a) concentrations. The concentrations of Lp(a) are under strict genetic control. There exists a continuous relationship between the Lp(a) concentrations and risk for various endpoints of atherosclerotic cardiovascular disease (ASCVD). One in five people in the Caucasian population is considered to have increased Lp(a) concentrations; the prevalence of elevated Lp(a) is even higher in black populations. This makes Lp(a) a cardiovascular risk factor of major public health relevance. Besides the association between Lp(a) and myocardial infarction, the relationship with aortic valve stenosis has become a major focus of research during the last decade. Genetic studies provided strong support for a causal association between Lp(a) and cardiovascular outcomes: carriers of genetic variants associated with lifelong increased Lp(a) concentration are significantly more frequent in patients with ASCVD. This has triggered the development of drugs that can specifically lower Lp(a) concentrations: mRNA-targeting therapies such as anti-sense oligonucleotide (ASO) therapies and short interfering RNA (siRNA) therapies have opened new avenues to lower Lp(a) concentrations more than 95%. Ongoing Phase II and III clinical trials of these compounds are discussed in this review.

Lipoprotein(a) and the Risk for Recurrent Atherosclerotic Cardiovascular Events Among Adults With CKD: The Chronic Renal Insufficiency Cohort (CRIC) Study

Rationale & Objective

Many adults with chronic kidney disease (CKD) and atherosclerotic cardiovascular disease (ASCVD) have high lipoprotein(a) levels. It is unclear whether high lipoprotein(a) levels confer an increased risk for recurrent ASCVD events in this population. We estimated the risk for recurrent ASCVD events associated with lipoprotein(a) in adults with CKD and prevalent ASCVD.

Study Design

Observational cohort study.

Setting & Participants

We included 1,439 adults with CKD and prevalent ASCVD not on dialysis enrolled in the Chronic Renal Insufficiency Cohort study between 2003 and 2008.

Exposure

Baseline lipoprotein(a) mass concentration, measured using a latex-enhanced immunoturbidimetric assay.

Outcomes

Recurrent ASCVD events (primary outcome), kidney failure, and death (exploratory outcomes) through 2019.

Analytical Approach

We used Cox proportional-hazards regression models to estimate adjusted HR (aHRs) and 95% CIs.

Results

Among participants included in the current analysis (mean age 61.6 years, median lipoprotein(a) 29.4 mg/dL [25th-75th percentiles 9.9-70.9 mg/dL]), 641 had a recurrent ASCVD event, 510 developed kidney failure, and 845 died over a median follow-up of 6.6 years. The aHR for ASCVD events associated with 1 standard deviation (SD) higher log-transformed lipoprotein(a) was 1.04 (95% CI, 0.95-1.15). In subgroup analyses, 1 SD higher log-lipoprotein(a) was associated with an increased risk for ASCVD events in participants without diabetes (aHR, 1.23; 95% CI, 1.02-1.48), but there was no evidence of an association among those with diabetes (aHR, 0.99; 95% CI, 0.88-1.10, P comparing aHRs = 0.031). The aHR associated with 1 SD higher log-lipoprotein(a) in the overall study population was 1.16 (95% CI, 1.04-1.28) for kidney failure and 1.02 (95% CI, 0.94-1.11) for death.

Limitations

Lipoprotein(a) was not available in molar concentration.

Conclusions

Lipoprotein(a) was not associated with the risk for recurrent ASCVD events in adults with CKD, although it was associated with a risk for kidney failure.

Incident CHD and ischemic stroke associated with lipoprotein(a) by levels of Factor VIII and inflammation

BACKGROUND

Inflammation and coagulation may contribute to the increased risk for atherosclerotic cardiovascular disease (ASCVD) associated with high lipoprotein(a). The association of lipoprotein(a) with ASCVD is stronger in individuals with high versus low high-sensitivity C-reactive protein (hs-CRP), a marker of inflammation.

OBJECTIVES

Determine the association of lipoprotein(a) with incident ASCVD by levels of coagulation Factor VIII controlling for hs-CRP.

METHODS

We analyzed data from 6,495 men and women 45 to 84 years of age in the Multi-Ethnic Study of Atherosclerosis (MESA) without prevalent ASCVD at baseline (2000-2002). Lipoprotein(a) mass concentration, Factor VIII coagulant activity, and hs-CRP were measured at baseline and categorized as high or low (≥75th or <75th percentile of the distribution). Participants were followed for incident coronary heart disease (CHD) and ischemic stroke through 2015.

RESULTS

Over a median follow-up of 13.9 years, there were 390 CHD and 247 ischemic stroke events. The hazard ratio (95%CI) for CHD associated with high lipoprotein(a) (≥40.1 versus <40.1 mg/dL) including adjustment for hs-CRP among participants with low and high Factor VIII was 1.07 (0.80-1.44) and 2.00 (1.33-3.01), respectively (p-value for interaction 0.016). The hazard ratio (95%CI) for CHD associated with high lipoprotein(a) including adjustment for Factor VIII was 1.16 (0.87-1.54) and 2.00 (1.29-3.09) among participants with low and high hs-CRP, respectively (p-value for interaction 0.042). Lp(a) was not associated with ischemic stroke regardless of Factor VIII or hs-CRP levels.

CONCLUSION

High lipoprotein(a) is a risk factor for CHD in adults with high levels of hemostatic or inflammatory markers.

Prognostic impacts of diabetes status and lipoprotein(a) levels in patients with ST-segment elevation myocardial infarction: a prospective cohort study

OBJECTS

This study aimed to investigate the impact of lipoprotein(a) [Lp(a)] levels on the prognosis of Chinese patients with ST-segment elevation myocardial infarction (STEMI), and to explore if the impact may differ in the diabetes mellitus (DM) and nonDM groups.

METHODS

Between March 2017 and January 2020, 1543 patients with STEMI who underwent emergency percutaneous coronary intervention (PCI) were prospectively recruited. The primary outcome was a composite of all-cause death, MI recurrence (reMI), and stroke, known as major adverse cardiovascular events (MACE). Analyses involving the Kaplan-Meier curve, Cox regression, and restricted cubic spline (RCS) were conducted.

RESULTS

During the 1446-day follow-up period, 275 patients (17.8%) experienced MACEs, including 141 with DM (20.8%) and 134 (15.5%) without DM. As for the DM group, patients with Lp(a) ≥ 50 mg/dL showed an apparently higher MACE risk compared to those with Lp(a) < 10 mg/dL (adjusted hazard ratio [HR]: 1.85, 95% confidence interval [CI]:1.10-3.11, P = 0.021). The RCS curve indicates that the HR for MACE appeared to increase linearly with Lp(a) levels exceeding 16.9 mg/dL. However, no similar associations were obtained in the nonDM group, with an adjusted HR value of 0.57 (Lp(a) ≥ 50 mg/dL vs. < 10 mg/dL: 95% CI 0.32-1.05, P = 0.071). Besides, compared to patients without DM and Lp(a) ≥ 30 mg/dL, the MACE risk of patients in the other three groups (nonDM with Lp(a) < 30 mg/dL, DM with Lp(a) < 30 mg/dL, and DM with Lp(a) ≥ 30 mg/dL) increased to 1.67-fold (95% CI 1.11-2.50, P = 0.013), 1.53-fold (95% CI 1.02-2.31, P = 0.041), and 2.08-fold (95% CI 1.33-3.26, P = 0.001), respectively.

CONCLUSIONS

In this contemporary STEMI population, high Lp(a) levels were linked to an increased MACE risk, and very high Lp(a) levels (≥ 50 mg/dL) significantly indicated poor outcomes in patients with DM, while not for those without DM.

TRIAL REGISTRATION

clinicaltrials.gov NCT: 03593928.

Are we seeing the light at the end of the tunnel for high lipoprotein(a)? Lipoprotein(a)

Lipoprotein (a) (Lp(a)) attests to be of interest as a new lipoprotein target. However, Lp(a) was discovered in 1963 and since then was recognized as a low-density lipoprotein (LDL)-like lipoprotein with a structurally similar domain to plasminogen. We are increasingly recognizing the importance of Lp(a) and cardiovascular pathologies including atherosclerotic cardiovascular disease, aortic valve stenosis, heart failure, and atrial fibrillation. However, we neither have a standardized measurement method nor an appropriate agent to intervene with this old threat that we have recognized for more than 50 years. Herein, we present an up-to-date review of our knowledge about Lp(a) covering measurement methods, its associates, and summary of the currently available therapies and emerging therapeutic agents for the management of high Lp(a) in the light of recent evidence and guideline recommendations

Inclisiran-A Revolutionary Addition to a Cholesterol-Lowering Therapy

Hypercholesterolemia plays a crucial role in the development of atherosclerosis, but it remains an undertreated and underdiagnosed disease. Taking into consideration the high prevalence of lipid disorders, long duration of the asymptomatic course of the disease, life-threatening complications resulting from inaccurate therapy, and stringent treatment goals concerning LDL cholesterol level in the prevention of cardiovascular events, novel lipid-lowering therapies have been introduced in the last few years. In this article, a drug belonging to the group of small interfering RNA (siRNA) called inclisiran is described. It is a novel molecule that increases the number of LDL receptors (LDLRs) on the surface of hepatic cells by preventing the formation of proprotein convertase subtilisin/kexin type 9 (PCSK9) responsible for the degradation of LDLRs. With great potential for lowering plasma LDL cholesterol level, high liver specificity, comfortable dosing regimen, and good tolerance without significant adverse effects, it could play an important part in future hypolipemic therapies.

Detection strategies for elevated lipoprotein(a): will implementation let the genie out of the bottle?

PURPOSE OF REVIEW

Elevated Lp(a) level is an important causal risk factor for atherosclerotic cardiovascular disease (ASCVD), principally coronary artery disease. Selective testing for Lp(a) is highly recommended in patients at intermediate and high risk for ASCVD. Lp(a) levels are predominantly genetically determined, and this has implications for cascade testing.

RECENT FINDINGS

Recent studies show that cascade testing is effective in identifying elevated Lp(a) in close relatives of probands with high Lp(a). Apart from selective testing and cascade testing as detection strategies, some recent guidelines recommend testing of Lp(a) in all adults at least once in their lifetime and various implementation strategies have been suggested.

SUMMARY

Hyper-Lp(a) is an important global health problem that can be easily detected. Hyper-Lp(a) meets all the criteria for universal screening except that there is not yet supportive evidence from clinical interventional trials showing a reduction of ASCVD events. The cost-effectiveness of the various detection and implementation strategies need to be further evaluated.

Australian Atherosclerosis Society Position Statement on Lipoprotein(a): Clinical and Implementation Recommendations

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.

High-Risk Lipoprotein(a) Levels in Saudi Women and Its Relationship to Menopause and Adiposity

Lipoprotein(a) is an inherent CVD risk biomarker that varies by race, and the levels of Lp(a) in Saudi women are relatively unexplored. We aimed to examine the effect of age and menopause on Lp(a) and explore the correlation between adiposity and cardiometabolic risk factors with Lp(a) in Saudi women. The third aim was to determine the predictors of elevated Lp(a) in this population. In this cross-sectional study of 229 women, we compared Lp(a) serum levels, adiposity indices, and lipid and glycemic profiles between menopausal groups. We used immunoturbidimetry to measure serum Lp(a) and BIA to assess body composition. We evaluated the relationship between Lp(a) and our parameters using ANOVA and Spearman's correlations. Regression was used to determine the predictors of high-risk Lp(a) levels. The mean of Lp(a) was 28.37 mg/dL, and the concentration increased significantly in postmenopausal (premenopausal 20.98 ± 12.30; perimenopausal 29.92 ± 9.53; postmenopausal 32.49 ± 9.83 mg/dL; p < 0.001. High-risk levels were 57.1% in postmenopausal and 19.1% in premenopausal. The magnitude of Lp(a) increased significantly after age 50. Lp(a) was significantly associated with age and cholesterol and negatively associated with % FFM. Lp(a) increased by 0.41 units for every year of age, indicating the strongest correlation.

Lipoprotein(a), Cardiovascular Events and Sex Differences: A Single Cardiological Unit Experience

Lipoprotein(a)-Lp(a), which retains proatherogenic and prothrombotic properties, may be modified by hormonal and metabolic factors. However, few studies have focused on differences related to sex and cardiometabolic risk factors in the relationship between Lp(a) and cardiovascular disease, especially in terms of prognosis. This study aimed at evaluating the predictive value of Lp(a) (cut-off 30 mg/dL) for hard events (HEs: mortality and non-fatal myocardial infarction) according to sex and cardiometabolic risk factors in 2110 patients (1501 males, mean age: 68 ± 9 years) undergoing coronary angiography for known or suspected coronary artery disease. There were 211 events over a median follow-up period of 33 months. Lp(a) > 30 mg/dL did not confer a worse prognosis on the overall population. However, Kaplan-Meier subgroup analysis evidenced a worse prognosis in type 2 diabetes (T2D) females with elevated Lp(a) (log-rank test: p = 0.03) vs. T2D males and no-T2D patients, but not in other high-risk cardiovascular states (e.g., smoking, hypertension, reduced left ventricular ejection fraction or obesity). After Cox multivariate adjustment, Lp(a) remained an independent determinant for HEs in the T2D female subgroup, conferring an HR of 2.9 (95% CI 1.1-7.7, p < 0.05). Lp(a) is therefore a strong independent predictor of HR in T2D women, but not in T2D men, or in noT2D patients.

Efficacy and safety of pelacarsen in lowering Lp(a) in healthy Japanese subjects

BACKGROUND

Pelacarsen is a liver-targeted antisense oligonucleotide that potently lowers lipoprotein(a) [Lp(a)] levels. Its safety and efficacy in diverse populations has not been extensively studied.

OBJECTIVE

To assess the effect of pelacarsen, including monthly dosing of 80 mg, in subjects of Japanese ancestry.

METHODS

A randomized double-blind, placebo-controlled, study was performed in 29 healthy Japanese subjects treated with single ascending doses (SAD) of pelacarsen 20, 40 and 80 mg subcutaneously or multiple doses (MD) of pelacarsen 80 mg monthly for 4 doses. The primary objective was to assess the safety and tolerability in healthy Japanese subjects; secondary objectives to assess the pharmacokinetics of pelacarsen; and exploratory objective to determine the effect of pelacarsen on plasma Lp(a) levels.

RESULTS

No serious adverse events or clinically relevant abnormalities in any laboratory parameters were noted. In the MD cohort, mean plasma concentrations of pelacarsen peaked at ∼4 hours and declined in a bi-exponential manner thereafter. In the SAD cohorts, the placebo-corrected least-square mean (PCLSM) percent changes in Lp(a) at Day 30 were: -55.4% (p=0.0008), -58.9% (p=0.0003) and -73.7% (p<0.0001) for the 20 mg, 40 mg, and 80 mg pelacarsen-treated groups, respectively. In the MD cohort, the PCLSM at Days 29, 85, 113, 176 and 204 were -84.0% (p=0.0003), -106.2% (p<0.0001), -70.0 (p<0.0001), -80.0% (p=0.0104) and -55.8% (p=0.0707), respectively.

CONCLUSIONS

Pelacarsen demonstrates an acceptable safety and tolerability profile and potently lowers plasma levels of Lp(a) in healthy Japanese subjects, including with the 80 mg monthly dose being evaluated in the Lp(a) HORIZON trial.

Relationship between lipoprotein(a) and colorectal cancer among inpatients: a retrospective study

The present study was to explore the association between lipoprotein(a) [Lp(a)] and colorectal cancer (CRC) among inpatients. This study included 2822 participants (393 cases vs. 2429 controls) between April 2015 and June 2022. Logistic regression models, smooth curve fitting, and sensitivity analyses were performed to investigate the relationship between Lp(a) and CRC. Compared with the lower Lp(a) quantile 1 (<79.6 mg/L), the adjusted odds ratios (ORs) in quantile 2 (79.6-145.0 mg/L), quantile 3 (146.0-299.0 mg/L), and quantile 4 (≥300.0 mg/L) were 1.41 (95% confidence interval [CI]: 0.95-2.09), 1.54 (95% CI: 1.04-2.27), 1.84 (95% CI: 1.25-2.7), respectively. A linear relationship between lipoprotein(a) and CRC was observed. The finding that Lp(a) has a positive association with CRC supports the "common soil" hypothesis of cardiovascular disease (CVD) and CRC.

Anabolic-androgenic steroids: How do they work and what are the risks?

Anabolic-androgenic steroids (AAS) are a class of hormones that are widely abused for their muscle-building and strength-increasing properties in high, nontherapeutic, dosages. This review provides an up-to-date and comprehensive overview on how these hormones work and what side effects they might elicit. We discuss how AAS are absorbed into the circulation after intramuscular injection or oral ingestion and how they are subsequently transported to the tissues, where they will move into the extravascular compartment and diffuse into their target cells. Inside these cells, AAS can biotransform into different metabolites or bind to their cognate receptor: the androgen receptor. AAS and their metabolites can cause side effects such as acne vulgaris, hypertension, hepatotoxicity, dyslipidemia, testosterone deficiency, erectile dysfunction, gynecomastia, and cardiomyopathy. Where applicable, we mention treatment options and self-medication practices of AAS users to counteract these side effects. Clinicians may use this review as a guide for understanding how AAS use can impact health and to assist in patient education and, in some cases, the management of side effects.

Targeted Treatment against Lipoprotein (a): The Coming Breakthrough in Lipid Lowering Therapy

Atherosclerotic cardiovascular diseases (ASCVD) are a very important cause of premature death. The most important risk factor for ASCVD is lipid disorders. The incidence of lipid disorders and ASCVD is constantly increasing, which means that new methods of prevention and treatment of these diseases are still being searched for. In the management of patients with lipid disorders, the primary goal of therapy is to lower the serum LDL-C concentration. Despite the available effective lipid-lowering therapies, the risk of ASCVD is still increased in some patients. A high level of serum lipoprotein (a) (Lp(a)) is a risk factor for ASCVD independent of serum LDL-C concentration. About 20% of Europeans have elevated serum Lp(a) levels, requiring treatment to reduce serum Lp(a) concentrations in addition to LDL-C. Currently available lipid lowering drugs do not sufficiently reduce serum Lp(a) levels. Hence, drugs based on RNA technology, such as pelacarsen, olpasiran, SLN360 and LY3819469, are undergoing clinical trials. These drugs are very effective in lowering the serum Lp(a) concentration and have a satisfactory safety profile, which means that in the near future they will fill an important gap in the armamentarium of lipid-lowering drugs.

New Horizons: Revival of Lipoprotein (a) as a Risk Factor for Cardiovascular Disease

The status of lipoprotein (a) [Lp(a)] as a cardiovascular risk factor has been resurrected by advances in genetics. Mendelian randomization studies show a causal link of Lp(a) with coronary artery disease (CAD), peripheral artery disease (PAD), and calcific aortic valve stenosis (CAVS). The genetics of Lp(a) is complex and extends beyond the kringle-IV type 2, as it is also dependent on ancestry. The plasma concentration of Lp(a) is determined by the hepatic production of apolipoprotein(a) [apo(a)] component of Lp(a), supporting the use of nucleic acids that inhibit the messenger RNA (mRNA) gene transcript for apo(a). Analytical barriers to measurement of Lp(a) are being addressed using isoform independent assays and a traceable standard. The association of Lp(a) and atherosclerotic cardiovascular disease is higher for myocardial infarction than PAD and CAVS. Increased risk of type 2 diabetes mellitus associated with low Lp(a) levels is perplexing and requires further investigation. The greatest advancement in Lp(a)-lowering therapies is based on using RNA therapeutics that are now being investigated in clinical trials. Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibition lowers Lp(a) modestly, but whether cardiovascular benefit is independent of low-density lipoprotein lowering remains unclear. Opportunistic and selective testing for Lp(a) is supported by moderate evidence, with the case for universal screening premature. Modification of behavioral and clinical risk factors may be targeted to mitigate Lp(a)-mediated risk of cardiovascular disease. Clinical practice guidelines have been developed to address gaps in care of high Lp(a), but full implementation awaits the findings of clinical outcome trials using RNA-directed therapies currently underway.

Prognostic Impacts of LL-37 in Relation to Lipid Profiles of Patients with Myocardial Infarction: A Prospective Cohort Study

Background. In vivo studies show that LL-37 inhibits the progression of atherosclerosis and predicts a lower risk of recurrent ischemia in patients with acute myocardial infarction (AMI), which could be mediated by the modulation of lipid metabolism. The current study aimed to investigate the effects of various lipid contents on the prognostic impacts of LL-37 in patients with AMI. Methods. A total of 1567 consecutive AMI patients were prospectively recruited from March 2017 to January 2020. Patients were firstly stratified into two groups by the median level of LL-37 and then stratified by levels of various lipid contents and proprotein convertase subtilisin/kexin type 9 (PCSK9). Cox regression with multiple adjustments was performed to analyze associations between LL-37, lipid profiles, PCSK9, and various outcomes. The primary outcome was major adverse cardiovascular event (MACE), a composite of all-cause death, recurrent MI, and ischemic stroke. Results. During a median follow-up of 786 (726−1107) days, a total of 252 MACEs occurred. A high level of LL-37 was associated with lower risk of MACE in patients with elevated lipoprotein(a) (≥300 mg/L, hazard ratio (HR): 0.49, 95% confidence interval (CI): 0.29−0.86, p = 0.012) or PCSK9 levels above the median (≥47.4 ng/mL, HR: 0.57, 95% CI: 0.39−0.82, p < 0.001), which was not observed for those without elevated lp(a) (<300 mg/L, HR: 0.96, 95% CI: 0.70−1.31, p = 0.781, pinteraction = 0.035) or PCSK9 (<47.4 ng/mL, HR: 1.02, 95% CI: 0.68−1.54, p = 0.905, pinteraction = 0.032). Conclusions. For patients with AMI, a high level of LL-37 was associated with lower ischemic risk among patients with elevated lp(a) and PCSK9.

Lipoprotein(a) in the Korean Pediatric Population Visiting Local Clinics and Hospitals

In this paper we investigate serum lipoprotein(a), an independent risk factor for cardiovascular disease in the Korean pediatric population. Visiting local clinics and hospitals, 600 lipoprotein(a) tests were performed on 416 Korean children and adolescents (124 boys and 292 girls), with a median age of 11.1 years (interquartile range, IQR, 9.8–13.9). The median lipoprotein(a) level was 21.5 nmol/L (IQR, 8.2–51.7). Among the 416 patients, the 90th percentile value of the initial lipoprotein(a) measurement was 107.8 nmol/L. The proportion of patients with lipoprotein(a) ≥ 100 nmol/L was 11.3%. The lipoprotein(a) level and the proportion of patients with lipoprotein(a) ≥ 100 nmol/L were not significantly different among sex, or age group. Among the 416 patients, 122 (29.3%, 21 boys and 101 girls) underwent at least two follow-up lipoprotein(a) measurements. The median follow-up period was 6.7 months (IQR, 5.5–11.8). The median lipoprotein(a) level across the 122 patients was 25 nmol/L (IQR 10.0–72.0). Among those patients, seven (5.7%) experienced an increase in serum lipoprotein(a) to ≥100 nmol/L during follow-up measurements. Further studies are needed in the Korean pediatric population in order to clarify the clinical significance of this change long-term.

Lipoprotein(a) measurement issues: Are we making a mountain out of a molehill?

Lipoprotein(a) [Lp(a)] became besides LDL cholesterol one of the most attractive targets for intervention in cardiovascular disease. Strong genetic evidence supports the causal association between high Lp(a) concentrations and cardiovascular outcomes. Since specific Lp(a)-lowering therapies are under clinical investigation, the interest in measuring Lp(a) has markedly increased. However, the special structure of the lead protein component of Lp(a), named apolipoprotein(a), creates difficulties for an accurate measurement of Lp(a). A highly homologous repetitive structure, called kringle IV repeat with up to more the 40 repeats, causes a highly polymorphic protein. Antibodies raised against apolipoprotein(a) are mostly directed against the repetitive structure of this protein, which complicates the measurement of Lp(a) in molar terms. Both measurements in mass (mg/dL) and molar terms (nmol/L) are described and a conversion from one into the another unit is only approximately possible. Working groups for standardization of Lp(a) measurements are going to prepare widely available and improved reference materials, which will be a major step for the measurement of Lp(a). This review discusses many aspects of the difficulties in measuring Lp(a). It tries to distinguish between academic and practical concerns and warns to make a mountain out of a molehill, which does no longer allow to see the patient behind that mountain by simply staring at the laboratory issues. On the other hand, the calibration of some assays raises major concerns, which are anything else but a molehill. This should be kept in mind and we should start measuring Lp(a) with the aim of a better risk stratification for the patient and to identify those patients who might be in urgent need for a specific Lp(a)-lowering therapy as soon as it becomes available.

Lipoprotein(a) and cardiovascular and valvular diseases: A genetic epidemiological perspective

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.