Lipoprotein(a), high-sensitivity C-reactive protein, and cardiovascular risk in patients undergoing percutaneous coronary intervention

Baseline High-Sensitivity C-Reactive Protein as a Predictor of Adverse Clinical Events in Patients with Coronary Artery Disease Undergoing Percutaneous Coronary Intervention: A Meta-Analysis

Inflammation in patients with coronary artery disease (CAD) has been linked to adverse clinical outcomes. A useful biomarker for measuring inflammation levels, high-sensitivity C-reactive protein (hs-CRP) in the blood can be used to detect the presence of low-grade inflammation. This study sought to assess the predictive value of baseline hs-CRP levels for adverse clinical events in CAD patients undergoing percutaneous coronary intervention (PCI). To investigate this topic, a meta-analysis was performed. We conducted a systematic search of PubMed, Embase, and the Cochrane Library for original articles reporting the correlation between hs-CRP levels and adverse clinical events in CAD patients undergoing PCI. We followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines and conducted a meta-analysis by extracting relevant data. Our pooled calculations yielded hazard ratios or odds ratios with 95% confidence intervals. A total of 28 studies comprising 60544 patients were included in this analysis. High baseline hs-CRP levels predicted increased risk for major adverse cardiac events ( P = 0.037), major adverse cardiac and cerebrovascular events ( P = 0.020), all-cause mortality ( P = 0.001), cardiovascular mortality ( P < 0.001), death and/or myocardial infarction ( P = 0.017) in patients, as well as restenosis ( P < 0.001). However, there was no association between elevated baseline hs-CRP levels and thrombosis. In conclusion, in CAD patients undergoing PCI, baseline hs-CRP levels are reliable predictors of major adverse cardiac events, major adverse cardiac and cerebrovascular events, all-cause mortality, cardiovascular mortality, death and/or myocardial infarction, and restenosis. Therefore, hs-CRP can effectively assist in prognosis determination for CAD patients undergoing PCI.

Impact of co-presence of malnutrition-inflammation-atherosclerosis factors on prognosis in lower extremity artery disease patients after endovascular therapy

Malnutrition and inflammation are common problems of adverse outcomes in various diseases as atherosclerosis. Recently, the concept of malnutrition-inflammation-atherosclerosis (MIA) syndrome is known to a crucial prognostic factor in patients with end-stage renal disease. We investigated the prognostic impact of the co-presence of MIA factors in patients with lower-extremity artery disease (LEAD) after endovascular therapy (EVT). This retrospective study included 284 patients with LEAD who underwent EVT. MIA factors were defined in patients with: low geriatric nutritional risk index (< 92) as "malnourished"; greater high-sensitivity C-reactive protein levels (≥ 0.1 mg/dL) as "inflamed"; a history of coronary artery revascularization, lacunar or atherothrombotic brain infarction as "atherosclerotic". We examined the relationship between baseline characteristics and major adverse cardiovascular and cerebrovascular events (MACCE) including all-cause mortality. Sixty-two patients (22%) died and 72 patients (25%) had MACCE, including all-cause death. Forty-four (16%) patients had every 3 of MIA (3-MIA) factors. The mean follow-up period was 737 days. Multivariate Cox proportional hazards regression analysis models revealed that 3-MIA factors correlated significantly with all-cause death [hazard ratio (HR) 3.46, 95% confidence interval (CI) 1.89-6.34; p < 0.001] and MACCE (HR 2.91, 95% CI 1.62-5.22; p < 0.001), after adjusting for relevant factors. Kaplan-Meier analysis revealed that the rates of all-cause death (p < 0.001) and MACCE (p < 0.001) were significantly higher when the MIA factors overlapped and are observed in patients with chronic limb-threatening ischemia. Among patients with LEAD after EVT, the co-presence of MIA factors was an independent risk factor for all-cause death and MACCE.

Association of Lipoprotein(a) With Major Adverse Cardiovascular Events Across hs-CRP: A Systematic Review and Meta-Analysis

Background

Lipoprotein(a) [Lp(a)] is an independent risk factor for atherosclerotic cardiovascular disease. The relationship between Lp(a) and major adverse cardiovascular events (MACE) in the context of high-sensitivity C-reactive protein (hs-CRP) levels remains controversial due to conflicting results from previous studies.

Objectives

This systematic review and meta-analysis aimed to clarify the association between Lp(a) and risk of MACE across different hs-CRP levels in both primary and secondary prevention settings.

Methods

We performed a systematic review by searching MEDLINE (PubMed), Embase (Ovid), Cochrane CENTRAL (Wiley), and Web of Science (Clarivate) from their inception to February 2024. Eligible studies reported the association of Lp(a) with MACE stratified by hs-CRP level. Data extraction and quality assessment were systematically conducted. Meta-analyses used random-effects models to compute pooled HRs for individuals with low (<2 mg/L) and high (≥2 mg/L) hs-CRP levels. Subgroup analyses were performed in primary and secondary prevention populations.

Results

Nine publications encompassing 11 studies that involved 562,301 participants met the inclusion criteria. The mean proportion of females was 39.9% and the weighted mean age for the entire cohort was 61.2 years. Elevated Lp(a) was significantly associated with MACE risk in both low and high hs-CRP groups, with pooled HR of 1.26 (95% CI: 1.11-1.42) and 1.33 (95% CI: 1.20-1.47), respectively. In the primary prevention group, the pooled HR for low and high hs-CRP groups was 1.33 (95% CI: 1.06-1.66) and 1.43 (95% CI: 1.13-1.82), respectively (subgroup difference, P = 0.65). The corresponding HRs for the secondary prevention population were 1.13 (95% CI: 1.00-1.27) and 1.31 (95% CI: 1.12-1.52), respectively (subgroup difference P = 0.13).

Conclusion

Elevated Lp(a) is associated with an increased risk of MACE independent of hs-CRP levels in both primary and secondary prevention populations.

Enhanced predictive performance of the GRACE risk score by incorporating lipoprotein(a) for major adverse cardiac events in acute myocardial infarction patients undergoing PCI

Background

As scientific research advances, the landscape of detection indicators and methodologies evolves continuously. Our current study aimed to identify some novel perioperative indicators that can enhance the predictive accuracy of the Global Registry of Acute Coronary Events (GRACE) score for the in-hospital major adverse cardiovascular events (MACEs) in patients with acute myocardial infarction.

Methods

A total of 647 adult patients with AMI admitted to the emergency department were consecutively enrolled in the retrospective research starting from June 2016 to September 2019. The endpoint was in-hospital MACE. Stepwise regression analysis and multivariate logistic regression were performed to select the indicators for the union model established by nomogram. Bootstrap with 1000 replicates was chosen as the internal validation of the union model. The area under the receiver operating curve (AUC) and calibration plot were used to evaluate the discrimination and calibration. Decision curve analysis (DCA) was performed to evaluate the clinical sufficiency of the nomogram. Akaike's information criterion (AIC) and Bayesian Information Criterion (BIC) were used to evaluate the goodness of fit.

Results

Lipoprotein(a) combined with serum uric acid, fasting blood glucose, and hemoglobin could improve the GRACE risk score. The AUC of the union model was 0.86, which indicated a better discriminative ability than the GRACE risk score alone (AUC, 0.81; P < 0.05). The calibration plots of the union model showed favorable consistency between the prediction of the model and actual observations, which was better than the GRACE risk score. DCA plots suggested that the union model had better clinical applicability than the GRACE risk score.

Conclusion

Lipoprotein(a) has shown promise in augmenting the predictive capability of the GRACE risk score, however, it may be beneficial to integrate it with other commonly used indicators.

Is There a Need for Sex-Tailored Lipoprotein(a) Cut-Off Values for Coronary Artery Disease Risk Stratification?

BACKGROUND

Lipoprotein(a) [Lp(a)] plasma level is a well-known risk factor for coronary artery disease (CAD). Existing data regarding the influence of sex on the Lp(a)-CAD relationship are inconsistent.

OBJECTIVE

To investigate the relationship between Lp(a) and CAD in men and women and to elucidate any sex-specific differences that may exist.

METHODS

Data of patients with Lp(a) measurements who were admitted to a tertiary university hospital, Koc University Hospital, were analyzed. The relationship between Lp(a) levels and CAD was explored in all patients and in subgroups created by sex. Two commonly accepted Lp(a) thresholds ≥ 30 and ≥ 50 mg/dL were analyzed.

RESULTS

A total of 1858 patients (mean age 54 ± 17 years; 53.33% females) were included in the analysis. Lp(a) was an independent predictor of CAD according to the multivariate regression model for the entire cohort. In all cohort, both cut-off values (≥ 30 and ≥ 50 mg/dL) were detected as independent predictors of CAD (p < 0.001). In sex-specific analysis, an Lp(a) ≥ 30 mg/dL was an independent predictor of CAD only in women (p < 0.001), but Lp(a) ≥ 50 mg/dL was a CAD predictor both in men and women (men, p = 0.004; women, p = 0.047).

CONCLUSION

The findings of this study may suggest that different thresholds of Lp(a) level can be employed for risk stratification in women compared to men.

Associations of HDL-C and ApoA-I with Mortality Risk in PCI Patients Across Different hsCRP Levels

Purpose

The association between high-density lipoprotein cholesterol (HDL-C) and apolipoprotein A-I (ApoA-I) and cardiovascular risk in patients with coronary artery disease remains inconsistent. Recent investigations indicated potential dysfunctionality of HDL under inflammation. This study endeavors to explore whether the inflammatory status modifies the effects of HDL-C and ApoA-I on cardiovascular risk in individuals with percutaneous coronary intervention (PCI).

Patients and Methods

Consecutive 10,724 PCI patients at Fuwai hospital in 2013 were enrolled. Inflammation status was defined by high-sensitivity C-reactive proteins (hsCRP) ≥ 2 mg/L. The study endpoint was cardiac mortality.

Results

Among 9569 PCI patients eventually included, 225 (2.4%) cardiac mortality happened during 5 years. In hsCRP ≥ 2 mg/L group, an U-shaped curve was observed for HDL-C and multivariate Cox regression showed that elevated risks of cardiac mortality correlated to both the lowest quintile (hazard ratio [HR], 2.50; 95% confidence interval [CI], 1.32-4.71) and the highest quintile of HDL-C (HR, 2.28; 95% CI, 1.23-4.25). However, an L-shaped curve existed in ApoA-I, indicating only the lowest quintile level of ApoA-I was associated with an increased cardiac mortality risk (HR, 2.19; 95% CI, 1.28-3.75). Nevertheless, in hsCRP < 2 mg/L group, no significant correlations between HDL-C and ApoA-I and cardiac mortality risk were identified (both P > 0.05).

Conclusion

In PCI patients with hsCRP ≥ 2 mg/L. both low and high HDL-C levels correlated with higher cardiac mortality risk (U-shaped), while only low ApoA-I levels were linked to elevated risk (L-shaped). However, in patients with hsCRP < 2 mg/L, neither HDL-C nor ApoA-I levels were associated with higher cardiac mortality risk. These findings shed light on the importance of considering inflammation status, particularly hsCRP levels, in managing HDL-C and ApoA-I levels, and suggest targeting elevated ApoA-I levels as a potential therapeutic approach for PCI patients with hsCRP ≥ 2 mg/L.

Inverse Association of Lipoprotein(a) on Long-Term Bleeding Risk in Patients with Coronary Heart Disease: Insight from a Multicenter Cohort in Asia

BACKGROUND

 Lipoprotein(a), or Lp(a), has been recognized as a strong risk factor for atherosclerotic cardiovascular disease. However, the relationship between Lp(a) and bleeding remains indistinct, especially in the secondary prevention population of coronary artery disease (CAD). This investigation aimed to evaluate the association of Lp(a) with long-term bleeding among patients with CAD.

METHODS

 Based on a prospective multicenter cohort of patients with CAD consecutively enrolled from January 2015 to May 2019 in China, the current analysis included 16,150 participants. Thus, according to Lp(a) quintiles, all subjects were divided into five groups. The primary endpoint was bleeding at 2-year follow-up, and the secondary endpoint was major bleeding at 2-year follow-up.

RESULTS

 A total of 2,747 (17.0%) bleeding and 525 (3.3%) major bleeding were recorded during a median follow-up of 2.0 years. Kaplan-Meier survival analysis showed the highest bleeding incidence in Lp(a) quintile 1, compared with patients in Lp(a) quintiles 2 to 5 (p < 0.001), while the incidence of major bleeding seemed similar between the two groups. Moreover, restricted cubic spline analysis suggested that there was an L-shaped association between Lp(a) and 2-year bleeding after adjustment for potential confounding factors, whereas there was no significant association between Lp(a) and 2-year major bleeding.

CONCLUSION

 There was an inverse and L-shaped association of Lp(a) with bleeding at 2-year follow-up in patients with CAD. More attention and effort should be made to increase the clinician awareness of Lp(a)'s role, as a novel marker for bleeding risk to better guide shared-decision making in clinical practice.

Inflammatory risk and clinical outcomes according to polyvascular atherosclerotic disease status in patients undergoing PCI

BACKGROUND

Individuals suffering from polyvascular atherosclerotic disease (PolyVD) face a higher likelihood of adverse cardiovascular events. Additionally, inflammation, assessed by high-sensitivity C-reactive protein (hsCRP), affects residual risk following percutaneous coronary intervention (PCI). We aimed to explore the interplay between PolyVD and hsCRP in terms of clinical outcomes after PCI.

METHODS

Patients undergoing PCI for chronic coronary disease at a tertiary center between January 2012 and February 2020 were included for the current analysis. PolyVD was defined by additional history of cerebrovascular and/or peripheral artery disease. HsCRP levels were defined as elevated when the measured baseline concentration was > 3 mg/L. The primary outcome of interest was major adverse cardiovascular events (MACE), a composite of all-cause mortality, spontaneous MI, or target vessel revascularization.

RESULTS

Overall, 10,359 participants were included in the current study, with 17.4% affected by PolyVD and 82.6% included in the non-PolyVD subgroup. Patients with PolyVD had higher hsCRP levels than those without. Among the PolyVD group, a larger proportion (33.6%) exhibited elevated hsCRP compared to the non-PolyVD group (24.7%). Patients with both PolyVD and elevated hsCRP levels had significantly higher adverse event rates than all other subgroups at 1-year follow-up. Furthermore, an independent association between elevated hsCRP and MACE was observed within the PolyVD population, while this was not the case for individuals without PolyVD.

CONCLUSION

A residual risk of adverse outcomes after PCI linked to inflammation appears to be present among individuals with PolyVD. This could help define further target populations for anti-inflammatory treatment options.

Synergistic effect of lipoprotein(a) and high-sensitivity C-reactive protein on the risk of all-cause and cardiovascular death in patients with acute myocardial infarction: a large prospective cohort study

Objective

Although lipoprotein(a) [Lp(a)] and high-sensitivity C-reactive protein (Hs-CRP) are closely associated with the mortality of acute myocardial infarction (AMI), their synergistic effect on the risk of death remains unknown. Therefore, this study aimed to explore the combined effect of Lp(a) and Hs-CRP on the incidence of all-cause and cardiovascular death in AMI patients.

Methods

A comprehensive cohort study enrolled 912 AMI patients, categorizing them into four groups based on Lp(a) and Hs-CRP levels: Group 1 [Lp(a) < 30 mg/dL & Hs-CRP < 2 mg/L], Group 2 [Lp(a) < 30 mg/dL & Hs-CRP ≥ 2 mg/L], Group 3 [Lp(a) ≥ 30 mg/dL & Hs-CRP < 2 mg/L], and Group 4 [Lp(a) ≥ 30 mg/dL & Hs-CRP ≥ 2 mg/L]. Cox regression analysis, Kaplan-Meier survival analysis and sensitivity analysis were employed to determine the combined effects of Lp(a) and Hs-CRP on the risk of all-cause and cardiovascular death.

Results

Over a median observation period of 38.98 months, 217 patients passed away, with 137 deaths attributed to cardiovascular causes. The multivariate Cox regression analysis revealed that in the comprehensively adjusted Model 3, only Lp(a) and the combination of Lp(a) and Hs-CRP exhibited a strong association with cardiovascular death risk. Specifically, for Lp(a) levels ≥ 30 mg/dL compared to < 30 mg/dL, the hazard ratio (HR) was 2.434 with a 95% confidence interval (CI) of 1.653-3.583 (P < 0.001); for log10(Lp(a)), the HR was 2.630 with a 95% CI of 1.530-4.523 (P < 0.001); for Group 4 versus Group 1, the HR was 2.346 with a 95% CI of 1.054-5.220 (P = 0.037); and for Group 4 versus Groups 1 + 2 + 3, the HR was 1.878 with a 95% CI of 1.284-2.748 (P = 0.001). Sensitivity analysis indicated that the synergy between Lp(a) and Hs-CRP continued to be independently associated with the risk of cardiovascular death. For Group 3 versus Group 1, the HR was 3.353 with a 95% CI of 1.133-9.917 (P = 0.029); for Group 4 versus Group 1, the HR was 3.710 with a 95% CI of 1.466-9.392 (P = 0.006); and for Group 4 versus Groups 1 + 2 + 3, the HR was 2.433 with a 95% CI of 1.620-3.656 (P < 0.001).

Conclusions

Compared to elevated levels of either Lp(a) or Hs-CRP alone, the concurrent high levels of both significantly increased the risk of cardiovascular death in patients with AMI, underscoring the importance of considering their combined effects in the prognostic management of AMI patients.

Prediction models for major adverse cardiovascular events after percutaneous coronary intervention: a systematic review

Background

The number of models developed for predicting major adverse cardiovascular events (MACE) in patients undergoing percutaneous coronary intervention (PCI) is increasing, but the performance of these models is unknown. The purpose of this systematic review is to evaluate, describe, and compare existing models and analyze the factors that can predict outcomes.

Methods

We adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 during the execution of this review. Databases including Embase, PubMed, The Cochrane Library, Web of Science, CNKI, Wanfang Data, VIP, and SINOMED were comprehensively searched for identifying studies published from 1977 to 19 May 2023. Model development studies specifically designed for assessing the occurrence of MACE after PCI with or without external validation were included. Bias and transparency were evaluated by the Prediction Model Risk Of Bias Assessment Tool (PROBAST) and Transparent Reporting of a multivariate Individual Prognosis Or Diagnosis (TRIPOD) statement. The key findings were narratively summarized and presented in tables.

Results

A total of 5,234 articles were retrieved, and after thorough screening, 23 studies that met the predefined inclusion criteria were ultimately included. The models were mainly constructed using data from individuals diagnosed with ST-segment elevation myocardial infarction (STEMI). The discrimination of the models, as measured by the area under the curve (AUC) or C-index, varied between 0.638 and 0.96. The commonly used predictor variables include LVEF, age, Killip classification, diabetes, and various others. All models were determined to have a high risk of bias, and their adherence to the TRIPOD items was reported to be over 60%.

Conclusion

The existing models show some predictive ability, but all have a high risk of bias due to methodological shortcomings. This suggests that investigators should follow guidelines to develop high-quality models for better clinical service and dissemination.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=400835, Identifier CRD42023400835.

Elevated High-Sensitivity C-Reactive Protein Level Enhances the Impact of Lipoprotein(a) on Platelet Reactivity in PCI Patients Treated with Clopidogrel

BACKGROUND

Recently, the effect of Lipoprotein(a) [Lp(a)] on thrombogenesis has aroused great interest, while inflammation has been reported to modify the Lp(a)-associated risks through an unidentified mechanism.

PURPOSE

This study aimed to evaluate the association between platelet reactivity with Lp(a) and high-sensitivity C-reactive protein (hs-CRP) levels in percutaneous intervention (PCI) patients treated with clopidogrel.

METHODS

Data were collected from 10,724 consecutive PCI patients throughout the year 2013 in Fuwai Hospital. High on-treatment platelet reactivity (HTPR) and low on-treatment platelet reactivity (LTPR) were defined as thrombelastography (TEG) maximum amplitude of adenosine diphosphate-induced platelet (MAADP) > 47 mm and < 31 mm, respectively.

RESULTS

6615 patients with TEG results were finally enrolled. The mean age was 58.24 ± 10.28 years and 5131 (77.6%) were male. Multivariable logistic regression showed that taking Lp(a) < 30 mg/dL and hs-CRP < 2 mg/L as the reference, isolated Lp(a) elevation [Lp(a) ≥ 30 mg/dL and hs-CRP < 2 mg/L] was not significantly associated with HTPR (P = 0.153) or LTPR (P = 0.312). However, the joint elevation of Lp(a) and hs-CRP [Lp(a) ≥ 30 mg/dL and hs-CRP ≥ 2 mg/L] exhibited enhanced association with both HTPR (OR:1.976, 95% CI 1.677-2.329) and LTPR (OR:0.533, 95% CI 0.454-0.627).

CONCLUSIONS

The isolated elevation of Lp(a) level was not an independent indicator for platelet reactivity, yet the concomitant elevation of Lp(a) and hs-CRP levels was significantly associated with increased platelet reactivity. Whether intensified antiplatelet therapy or anti-inflammatory strategies could mitigate the risks in patients presenting combined Lp(a) and hs-CRP elevation requires future investigation.

C-Reactive Protein: Pathophysiology, Diagnosis, False Test Results and a Novel Diagnostic Algorithm for Clinicians

The current literature provides a body of evidence on C-Reactive Protein (CRP) and its potential role in inflammation. However, most pieces of evidence are sparse and controversial. This critical state-of-the-art monography provides all the crucial data on the potential biochemical properties of the protein, along with further evidence on its potential pathobiology, both for its pentameric and monomeric forms, including information for its ligands as well as the possible function of autoantibodies against the protein. Furthermore, the current evidence on its potential utility as a biomarker of various diseases is presented, of all cardiovascular, respiratory, hepatobiliary, gastrointestinal, pancreatic, renal, gynecological, andrological, dental, oral, otorhinolaryngological, ophthalmological, dermatological, musculoskeletal, neurological, mental, splenic, thyroid conditions, as well as infections, autoimmune-supposed conditions and neoplasms, including other possible factors that have been linked with elevated concentrations of that protein. Moreover, data on molecular diagnostics on CRP are discussed, and possible etiologies of false test results are highlighted. Additionally, this review evaluates all current pieces of evidence on CRP and systemic inflammation, and highlights future goals. Finally, a novel diagnostic algorithm to carefully assess the CRP level for a precise diagnosis of a medical condition is illustrated.

C-Reactive Protein Level and the Genetic Variant rs1130864 in the CRP Gene as Prognostic Factors for 10-Year Cardiovascular Outcome

BACKGROUND

Cardiovascular disease (CVD) is the primary cause of premature death and disability worldwide. There is extensive evidence that inflammation represents an important pathogenetic mechanism in the development and prognosis of CVD. C-reactive protein (CRP) is a potential marker of vascular inflammation and plays a direct role in CVD by promoting vascular inflammation. The objective of this study (ClinTrials.gov identifier: NCT01045070) was to assess the prognostic impact of CRP protein levels and genetic variants of CRP gene events on cardiovascular (CV) outcome (10-year follow-up) in patients suffering from CVD.

METHODS

CVD patients were prospectively included in this study (n = 1002) and followed up (10 years) regarding combined CV endpoint (CV death, death from stroke, myocardial infarction (MI), and stroke/transient ischemic attack (TIA)). CRP protein level (particle-enhanced immunological turbidity test) and genetic variants (rs1130864, rs1417938, rs1800947, rs3093077; polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) after DNA extraction from EDTA-blood) were evaluated.

RESULTS

In survival analyses, increased CRP protein levels of ≥5 mg/L (log-rank test: p < 0.001, Cox regression: p = 0.002, hazard ratio = 1.49) and CT + TT genotype of rs1130864 (log-rank test: p = 0.041; Cox regression: p = 0.103, hazard ratio = 1.21) were associated with a weaker CV prognosis considering combined CV endpoint.

CONCLUSIONS

Elevated CRP level and genetic variant (rs1130864) were proven to provide prognostic value for adverse outcome in CVD patients within the 10-year follow-up period.

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.