Lipoprotein(a) and Cardiovascular Disease in Chinese Population: A Beijing Heart Society Expert Scientific Statement

The Brussels International Declaration on Lipoprotein(a) Testing and Management

There is striking evidence that a high lipoprotein(a) [Lp(a)] concentration is a strong, independent, and causal cardiovascular risk factor. However, Lp(a) testing rates are very low (1 %-2 %) despite the fact that 1 in 5 individuals have elevated Lp(a) concentrations. The Brussels International Declaration on Lp(a) Testing and Management was co-created by the Lp(a) International Task Force and global leaders at the Lp(a) Global Summit, held in Brussels, Belgium, on March 24-25, 2025. The event, organized by FH Europe Foundation, brought together scientific experts, people with the lived experience of elevated Lp(a) and policy makers from the European Institutions and World Health Organization. The World Heart Federation, Global Heart Hub, and European Alliance for Cardiovascular Health and scientific organizations such as European Atherosclerosis Society, and International Atherosclerosis Society were formal partners. The Summit was hosted by a Member of the European Parliament, Romana Jerković, and held under the patronage of the Polish presidency of the Council of the European Union. The Declaration calls for 1) integration of Lp(a) testing and management into Global, European and National Cardiovascular Health Plans; 2) appropriate investment, policy and programmes in targeting Lp(a) testing and management based on a recent study demonstrating the substantial overall cost-saving to health systems across the globe; 3) political commitment to mandate systematic Lp(a) testing at least once during a person's lifetime, ideally at an early age, with full reimbursement; 4) incorporation of Lp(a) test results in the context of a person's cardiovascular risk assessment, with development of personalised cardiovascular health roadmaps as needed, without fear of discrimination; 5) investment in public and healthcare professional education to increase awareness of Lp(a) and its impact on cardiovascular health.

Causal Relevance of Lp(a) for Coronary Heart Disease and Stroke Types in East Asian and European Ancestry Populations: A Mendelian Randomization Study

BACKGROUND

Elevated plasma levels of Lp(a) [lipoprotein(a)] are a causal risk factor for coronary heart disease and stroke in European individuals, but the causal relevance of Lp(a) for different stroke types and in East Asian individuals with different Lp(a) genetic architecture is uncertain.

METHODS

We measured plasma levels of Lp(a) in a nested case-control study of 18 174 adults (mean [SD] age, 57 [10] years; 49% female) in the China Kadoorie Biobank (CKB) and performed a genome-wide association analysis to identify genetic variants affecting Lp(a) levels, with replication in ancestry-specific subsets in UK Biobank. We further performed 2-sample Mendelian randomization analyses, associating ancestry-specific Lp(a)-associated instrumental variants derived from CKB or from published data in European individuals with risk of myocardial infarction (n=17 091), ischemic stroke (IS [n=29 233]) and its subtypes, or intracerebral hemorrhage (n=5845) in East Asian and European individuals using available data from CKB and genome-wide association analysis consortia.

RESULTS

In CKB observational analyses, plasma levels of Lp(a) were log-linearly and positively associated with higher risks of myocardial infarction and IS, but not with ICH. In genome-wide association analysis, we identified 29 single nucleotide polymorphisms independently associated with Lp(a) that together explained 33% of variance in Lp(a) in Chinese individuals. In UK Biobank, the lead Chinese variants identified in CKB were replicated in 1260 Chinese individuals, but explained only 10% of variance in Lp(a) in European individuals. In Mendelian randomization analyses, however, there were highly concordant effects of Lp(a) across both ancestries for all cardiovascular disease outcomes examined. In combined analyses of both ancestries, the proportional reductions in risk per 100 nmol/L lower genetically predicted Lp(a) levels for myocardial infarction were 3-fold greater than for total IS (rate ratio, 0.78 [95% CI, 0.76-0.81] versus 0.94 [0.92-0.96]), but were similar to those for large-artery IS (0.80 [0.73-0.87]; n=8134). There were weaker associations with cardioembolic IS (0.92 [95% CI, 0.86-0.98]; n=11 730), and no association with small-vessel IS (0.99 [0.91-1.07]; n=12 343) or with intracerebral hemorrhage (1.08 [0.96-1.21]; n=5845).

CONCLUSIONS

The effects of Lp(a) on risk of myocardial infarction and large-artery IS were comparable in East Asian and European individuals, suggesting that people with either ancestry could expect comparable proportional benefits for equivalent reductions in Lp(a), but there was little effect on other stroke types.

Prevalence of Elevated Lipoprotein(a) and its Association With Subclinical Atherosclerosis in 2.9 Million Chinese Adults

BACKGROUND

Elevated lipoprotein(a) [Lp(a)] is strongly associated with an increased risk of atherosclerotic cardiovascular disease; yet, large-scale studies on the epidemiology of elevated Lp(a) as well as its association with subclinical atherosclerosis in the Chinese population are limited.

OBJECTIVES

This study aimed to estimate the prevalence of elevated Lp(a) in a large check-up population of China, and investigate its associations with both site-specific and multisite subclinical atherosclerosis.

METHODS

Adults who underwent Lp(a) testing between 2017 and 2023 at Meinian health check-up centers in 30 provinces of China were included. Because the test results of Lp(a) were reported in either the mass unit (mg/dL) or the molar unit (nmol/L) and conversion between units was not recommended, separate analyses were conducted for each unit. Subclinical atherosclerosis was assessed using various imaging examinations at the carotid artery, the brain, and the coronary artery. The prevalence of elevated Lp(a) was estimated across the overall study population and various subpopulations. The logistic regression model was used to investigate the associations between elevated Lp(a) and subclinical atherosclerosis.

RESULTS

A total of 2,788,206 and 167,114 participants with the mass unit and the molar unit were included. In the mass unit group, the prevalence of Lp(a) >30 and >50 mg/dL was 18.67% and 8.41%, respectively. Significantly higher prevalence was observed among women, elderly individuals, and individuals with various cardio-renal-metabolic risk factors (all P < 0.05). Compared with Lp(a) ≤30 mg/dL, individuals with Lp(a) >30 to ∼50 mg/dL exhibited 11%, 15%, 9%, and 11% greater odds of increased carotid intima-media thickness, carotid plaque, subclinical brain infarcts, and coronary artery calcification, respectively. The odds were even higher for those with Lp(a) >50 mg/dL. Furthermore, elevated Lp(a) was significantly associated with the extent of coronary artery calcification, as well as subclinical atherosclerosis at 1, 2, and 3 sites, with the association being more pronounced in cases with severe extent and multisite involvement. These results were similar in the molar unit group.

CONCLUSIONS

A significant burden of elevated Lp(a) was found in China, highlighting the necessity of prioritized Lp(a) screening in high-risk groups. Elevated Lp(a) was identified as a significant risk factor for site-specific subclinical atherosclerosis, with stronger associations observed in severe extent and multisite involvement. Our findings suggest that individuals with elevated Lp(a) should undergo a comprehensive assessment of subclinical atherosclerosis at multiple sites to help prevent ASCVD.

Stroke Prognosis: The Impact of Combined Thrombotic, Lipid, and Inflammatory Markers

AIM

D-dimer, lipoprotein (a) (Lp(a)), and high-sensitivity C-reactive protein (hs-CRP) are known predictors of vascular events; however, their impact on the stroke prognosis is unclear. This study used data from the Third China National Stroke Registry (CNSR-III) to assess their combined effect on functional disability and mortality after acute ischemic stroke (AIS).

METHODS

In total, 9,450 adult patients with AIS were enrolled between August 2015 and March 2018. Patients were categorized based on a cutoff value for D-dimer, Lp(a), and hs-CRP in the plasma. Adverse outcomes included poor functional outcomes (modified Rankin Scale (mRS score ≥ 3)) and one- year all-cause mortality. Logistic and multivariate Cox regression analyses were performed to investigate the relationship between individual and combined biomarkers and adverse outcomes.

RESULTS

Patients with elevated levels of all three biomarkers had the highest odds of functional disability (OR adjusted: 2.01; 95% CI (1.47-2.74); P＜0.001) and mortality (HR adjusted: 2.93; 95% CI (1.55-5.33); P＜0.001). The combined biomarkers improved the predictive accuracy for disability (C-statistic 0.80 vs.0.79, P＜0.001) and mortality (C-statistic 0.79 vs.0.78, P=0.01).

CONCLUSION

Elevated D-dimer, Lp(a), and hs-CRP levels together increase the risk of functional disability and mortality one-year post-AIS more than any single biomarker.

Impact of lipoprotein (a) on coronary atherosclerosis and plaque progression in patients with type 2 diabetes mellitus

OBJECTIVES

To explore the association between baseline Lp (a) levels and high-risk plaques, plaque volume, and plaque progression in patients with diabetes mellitus.

METHODS

Patients with diabetes mellitus and intermediate pretest probability of coronary artery disease (CAD) were prospectively enrolled. All patients underwent baseline coronary computed tomography angiography (CCTA), and patients with recurrent symptoms underwent mid-term follow-up CCTA. Plaque quantification and qualification were performed to compare coronary atherosclerosis features and plaque progression between the elevated and normal Lp (a) groups.

RESULTS

In this study, 1694 subjects (mean age: 62.0 ± 7.0 years; 1031 males) were enrolled for baseline analysis, and 246 subjects with repeat CCTA (mean interval of 2.3 ± 0.74 years) were included for follow-up analysis. The total plaque volume, noncalcified plaque volume, low attenuation plaque (LAP) volume, fibro-fatty plaque volume, and fibrotic plaque volume were higher in the elevated Lp (a) group than in the normal Lp (a) group at baseline (all p < 0.001). At follow-up, the elevated Lp (a) group showed a higher mean annual increase in LAP volume than the normal Lp (a) group (3.03 ± 22.26 mm3 vs -3.09 ± 12.22 mm3; p = 0.011). In multivariate linear regression analysis, elevated Lp (a) levels were associated with accelerated LAP volume progression after adjusting for confounders (Beta = 4.50, 95% confidence interval: 0.06-8.93; p = 0.045).

CONCLUSION

Elevated Lp (a) level in patients with diabetes mellitus was associated with high coronary artery plaque burden at baseline and LAP volume progression at follow-up.

KEY POINTS

Question The relationship between Lp (a) levels and coronary artery plaque volume and progression in patients with diabetes mellitus remains unclear. Findings Elevated Lp (a) level was associated with high total coronary plaque volume at baseline and low-attenuation plaque (LAP) volume progression at follow-up. Clinical relevance Elevated Lp (a) level in patients with diabetes mellitus was associated with high coronary artery plaque burden at baseline and LAP volume progression at follow-up, which supports the modulation of LAP level to improve prognosis.

Association between lipoprotein(a) and atherosclerosis with different diabetic status: a cross-sectional study in a Chinese population

Background

Lipoprotein(a) [Lp(a)] levels and diabetic status have been recognized as risk factors for atherosclerosis. However, no studies on atherosclerosis have integrated these two indicators. This study aimed to evaluate the relationship between Lp(a) levels, diabetic status, and their combined effects on subclinical atherosclerosis.

Methods

This cross-sectional study included patients presenting with a first episode of chest pain at the First Affiliated Hospital of Chongqing Medical University from June 2018 to February 2022. All participants underwent coronary computed tomography angiography (CCTA) and carotid ultrasound to evaluate subclinical atherosclerosis. Logistic regression analysis was used to examine the associations of Lp(a) levels and diabetic status-both individually and in combination-with coronary artery calcium (CAC) and carotid arteriopathy.

Results

Among 912 patients, 473 (51.9%) had CAC and 637 (69.8%) had carotid arteriopathy. After adjusting the confounding variables, elevated Lp(a) levels associated with CAC [odds ratio (OR) 1.51, 95% confidence interval (CI): 1.02-2.24, P=0.040] and carotid arteriopathy (OR 1.77, 95% CI: 1.10-2.86, P=0.02) were statistically significant. After combining diabetic status, almost all Lp(a) levels were significantly associated with CAC and CAC score categories (CAC scores: 0.1-99.9, 100-399.9, ≥400) in the diabetes mellitus (DM) group. In this group, the highest risk for CAC and the most severe CAC score categories were observed in patients with Lp(a) levels of >300 mg/L. Among patients with DM, in the lower Lp(a) level group, the prevalence and severity of CAC were more pronounced than those in the medium Lp(a) level group. Additionally, in patients with DM only, elevated Lp(a) levels were associated with carotid arteriopathy (OR 3.38, 95% CI: 1.24-9.20; P=0.02), increased carotid intima-media thickness (cIMT; OR 3.67, 95% CI: 1.10-12.30; P=0.04), and stable/vulnerable carotid plaque (OR 3.39, 95% CI: 1.09-10.55; P=0.04; OR 3.21, 95% CI: 1.07-9.65; P=0.04). However, there were no significant differences between prediabetes and CAC or carotid arteriopathy.

Conclusions

In patients with chest pain and DM without cardiovascular disease (CVD), Lp(a) level was significantly associated with subclinical atherosclerosis and had a synergistic effect with DM. Notably, lower Lp(a) levels in patients with DM may lead to an additional subclinical atherosclerosis risk, whereas prediabetes does not show the same association. Therefore, these findings highlight the importance of formulating early preventive strategies for subclinical atherosclerosis based on Lp(a) levels and diabetic status.

2024: The year in cardiovascular disease - the year of lipoprotein(a). Research advances and new findings

Elevated plasma lipoprotein(a) [Lp(a)] levels, which occur in as many as 1.5 billion people worldwide, are an independent and causal risk factor for atherosclerotic cardiovascular disease and calcific aortic valve disease. Unlike low-density lipoprotein cholesterol, Lp(a) levels are approximately 70-90% genetically determined. Currently, no approved pharmacological therapies specifically target lowering Lp(a) concentrations. Several drugs, mainly RNA-based therapies, that specifically and potently lower Lp(a), are under investigation. Three of these new therapeutic agents are advancing through clinical development to evaluate whether reducing Lp(a) levels can decrease cardiovascular risk. The outcomes of these trials could potentially transform cardiovascular disease prevention strategies; however, once approved, the drugs will likely be used for secondary prevention, and ongoing strategies for managing elevated Lp(a) in primary prevention will be important. Lipoprotein(a) research is a rapidly evolving field, but unanswered questions remain concerning the physiological function of Lp(a) and its true pathogenic mechanisms. This review of Lp(a) research focuses on new findings and clinical trial results that appeared in 2024.

Prognostic Impact of 1-Year Changes in Creatinine- and Cystatin C-Based Estimated Glomerular Filtration Rate After Stroke on 5-Year Outcomes: Insights From the Third China National Stroke Registry

BACKGROUND

The impact of long-term renal function change on stroke outcomes remains unclear. This study used the CNSR-III (Third China National Stroke Registry) cohort to determine whether changes in estimated glomerular filtration rate based on creatinine and cystatin C (eGFRCr+CysC) during the first year post stroke were associated with 5-year stroke outcomes.

METHODS AND RESULTS

We included 4270 patients with centrally tested serum creatinine and cystatin C at admission and 1 year post admission and evaluated 5-year follow-up data. Patients were stratified into quintiles based on the 1-year changes in eGFR. The primary outcomes included all-cause mortality, stroke disability, and stroke recurrence. In patients with acute ischemic stroke, the mean baseline eGFRCr+CysC was 88.6±22.6 mL/min per 1.73 m2, which decreased by 5.6% to 83.6±20.7 mL/min per 1.73 m2 at 1 year. Compared with patients with relatively stable eGFRCr+CysC (Q3), those with decreased eGFRCr+CysC (Q1) exhibited significantly increased adjusted risk of death (hazard ratio [HR], 1.96 [95% CI, 1.27-3.04], P=0.003) and those with increased eGFRCr+CysC (Q5) exhibited borderline significance (HR, 1.51 [95% CI, 0.94-2.42], P=0.09), after adjusting for confounders, including baseline eGFRCr+CysC and albumin-to-creatinine ratio. Patients with a significant decrease (odds ratio [OR], 1.74 [95% CI, 1.25-2.42], P=0.001) or increase (OR, 1.51 [95% CI, 1.06-2.15], P=0.02) in eGFRCr+CysC also experienced a higher risk of disability.

CONCLUSIONS

Both the decline and increase in eGFRCr+CysC levels in the first year post stroke were independently associated with all-cause mortality and stroke disability. These findings indicate that monitoring eGFRCr+CysC changes could be important for predicting long-term outcomes and informing poststroke care strategies.

Multimodal data-based longitudinal prognostic model for predicting atrial fibrillation recurrence after catheter ablation in patients with patent foramen ovale and paroxysmal atrial fibrillation

BACKGROUND

Clinical studies on atrial fibrillation (AF) recurrence after catheter ablation in patients diagnosed with patent foramen ovale (PFO) and paroxysmal AF (PAF) are scarce. Here, we aimed to develop a nomogram model utilizing multimodal data for the risk stratification of AF recurrence following catheter ablation in individuals diagnosed with PFO and new-onset PAF.

METHODS

Patients with PFO and PAF who underwent catheter ablation at the Renmin Hospital of Wuhan University from January 2018 to June 2020 were consecutively enrolled. The identification of potential risk factors was conducted using the regression method known as least absolute shrinkage and selection operator. Subsequently, multivariate COX regression analysis was conducted to determine the independent risk factors, after which a nomogram scoring system was developed. The nomogram's performance was assessed via various statistical measures, including receiver operating characteristic curve analysis, calibration curve, and decision curve analysis (DCA).

RESULTS

The dataset was partitioned into the development cohort (n = 102) and the validation cohort (n = 43) using a 7:3 ratio. The constructed nomogram included four clinical variables: age, diabetes mellitus, lipoprotein (a), and right ventricular diameter. The area under the curve values of the development and validation cohorts at 1, 2, and 3 years post-catheter ablation were 0.911, 0.812, and 0.786 and 0.842, 0.761, and 0.785, respectively. Additionally, the nomogram demonstrated a significant correlation between the predicted and actual outcomes in the development and validation cohorts, indicating its excellent calibration. Lastly, the DCA findings suggested that the model had notable clinical applicability in predicting the likelihood of AF recurrence within 1, 2, and 3 years after catheter ablation.

CONCLUSION

The incorporation of multimodal data in a nomogram visualization tool facilitates the concise representation of multimodal data, thereby enhancing the comprehension of the clinical status of patients with PFO and PAF following catheter ablation and providing accurate risk stratification at 1, 2, and 3 years post-treatment.

TRIAL REGISTRATION

This trial was registered in the Chinese Clinical Trial Registry. (ChiCTR2300072320).

Statins-Their Effect on Lipoprotein(a) Levels

Lipoprotein(a) (Lp(a)) serum concentration plays a crucial role as a risk factor in cardiovascular diseases and is gaining more and more attention. Patients with elevated lipoprotein(a) levels are often prescribed statins as they also have high concentrations of low-density lipoprotein cholesterol (LDL-C). Statins are drugs that successfully decrease LDL-C, but their effectiveness in Lp(a) levels reduction is uncertain. The aim of this study was to evaluate if statin therapy can affect Lp(a) concentration. A literature search on databases like PubMed, Oxford Academic, ScienceDirect, Embase, The Cochrane Library, Scopus, and Springer Link was conducted from 1 May to 10 August 2024 with the aim of finding studies concerning the effect of statins on Lp(a) levels. Only randomised control studies and studies with a placebo/comparator arm were included. For calculations, SPSS Statistics software version 29 was used. The risk of bias for this study was assessed using the revised Cochrane risk-of-bias tool for randomised trials. Overall, 43 studies (13,264 participants in study arms and 11,676 in control arms) were included in the analysis. The mean difference of absolute change in Lp(a) concentration for all 43 studies equaled 0.22 mg/dL and was not clinically significant. Egger's regression-based test resulted in no risk of bias in this study (p = 0.404). In conclusion, statin therapy does not significantly affect Lp(a) levels. Results of this work suggest that people with high Lp(a) levels will not change their Lp(a)-associated cardiovascular (CV) risk by statin administration.

Lipoprotein(a) and Atrial Fibrillation: Mechanistic Insights and Therapeutic Approaches

Elevated lipoprotein(a) [Lp(a)] levels are increasingly recognized as a significant risk factor for cardiovascular diseases and may also contribute to atrial fibrillation (AF). This review investigated the indirect mechanisms through which Lp(a) may influence AF, including proatherogenic, prothrombotic, and proinflammatory pathways. Traditional lipid-lowering therapies, such as lifestyle modifications and statins, have limited effects on Lp(a) levels. Emerging treatments, such as proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, lipoprotein apheresis, small interfering RNA, antisense oligonucleotides, cholesterol ester transfer protein inhibitors, and interleukin-6 receptor monoclonal antibodies, are promising alternatives. Notably, only PCSK9 inhibitors and lipoprotein apheresis have been shown to reduce both Lp(a) levels and cardiovascular events. Research indicates varying associations between Lp(a) and AF across different populations, underscoring the need for diverse, large-scale studies to elucidate these differences. Ongoing trials aim to provide clearer insights into these relationships. Addressing these gaps is essential for developing targeted therapies to manage elevated Lp(a) and mitigate the risk of AF and associated cardiovascular events.

Prognostic role of lipoprotein(a) in atherosclerotic cardiovascular disease risk from a perspective on current risk stratification

Lipoprotein(a) [Lp(a)] is an emerging predictor for atherosclerotic cardiovascular disease (ASCVD) but the association from a perspective on current risk stratification was unknown. A cohort of 9944 Chinese patients with ASCVD was recruited and refined into very-high-risk (VHR) and non-VHR subgroups according to current guideline. Lp(a) plasma levels were divided by its concentration (<30, 30-50, 50-75, and ≥75 mg/dL) and percentile zones (<25th, 25-50th, 50-75th, 75-90th, ≥90th). Cardiovascular events (CVEs) occurred during an average of 38.5 months' follow-up were recorded. We found that Lp(a) was increased with risk stratification of ASCVD increasing. Prevalence of CVEs had a significantly increasing trend with gradients of Lp(a) elevation in VHR but not in non-VHR subgroup. The adjusted HRs (95%CIs) for CVEs were 1.75(1.25-2.46) in the highest group of Lp(a) ≥75 mg/dL compared with the group of Lp(a) <30 mg/dL as the reference in overall patients, 2.18(1.32-3.58) in VHR subgroup and 1.43(0.93-2.18) in non-VHR subgroup, respectively. The adjusted HRs (95%CIs) at the highest grade of Lp(a) levels (≥90th) were 1.72(1.19-2.50) in overall population, 2.83(1.53-5.24) in VHR subgroup and 1.38(0.86-2.12) in non-VHR subgroup, respectively. These findings suggested that Lp(a) might contribute more to CVEs risk in VHR subgroup of ASCVD.

Association between lipoprotein(a) and cardiovascular disease in patients undergoing coronary angiography

OBJECTIVE

Many previous studies reported the relationship between lipoprotein(a) and cardiovascular disease, but the conclusions were controversial. The aim of our study was to retrospectively investigate the association between lipoprotein(a) and cardiovascular disease in patients undergoing coronary angiography.

METHODS

We collected and compared clinical information of patients hospitalized for coronary angiography. Multivariable hierarchical logistic regression was used to evaluate the association between lipoprotein(a) and cardiovascular disease in patients undergoing coronary angiography.

RESULTS

There were no significant differences in gender, hypertension, APOA1, smoking, hyperuricemia, obesity, acute myocardial infarction (AMI), cardiac insufficiency, family history of diabetes, or family history of hyperlipidemia among the four groups of lipoprotein(a). Elevated lipoprotein(a) does not increase the risk of hypertriglyceridemia, while elevated lipoprotein(a) increases the risk of high total cholesterol and high low-density lipoprotein cholesterol (LDL-c). Elevated lipoprotein(a) increases the risk of diabetes and premature coronary artery disease (CAD). Elevated lipoprotein(a) increases the incidence of CAD, multivessel lesions, and percutaneous coronary intervention (PCI). Multivariate logistic regression analysis further showed that elevated lipoprotein(a) increases the incidence of high total cholesterol, high LDL‑c, diabetes, CAD, premature CAD, multivessel lesions, and PCI.

CONCLUSION

The findings indicated that elevated lipoprotein(a) had no obvious relationship with hypertension and obesity. Elevated lipoprotein(a) increases the risk of high total cholesterol, high LDL‑c, and premature CAD, and increases the occurrence and severity of coronary heart disease.

Lipoprotein(a) and ischemic stroke: current insights and knowledge gaps

Lipoprotein(a) [Lp(a)], a particle similar to low-density lipoprotein, has been consistently identified as a significant risk factor for cardiovascular disease (CVD). Emerging data from epidemiological observation and genetic studies have demonstrated that elevated levels of Lp(a), primarily influenced by genetic variation, are associated with an increased risk of ischemic strokes (IS). This association may be attributed to the proatherogenic, proinflammatory, and prothrombotic properties of Lp(a). Although therapeutic interventions specifically aimed at reducing Lp(a) levels are still under development, understanding the relationship of Lp(a) and IS could aid in the management of IS. This review aims to present the clinical evidence, pathophysiological mechanisms, and potential implications linking Lp(a) to IS, with the goal of raising awareness of Lp(a) in real-world clinical practice for IS prevention and treatment.

The levels of serum lipoprotein(a) on clinical outcomes in Chinese hospitalized patients with cardiovascular diseases

OBJECTIVE

Serum lipoprotein(a) [Lp(a)] is a risk factor of cardiovascular diseases. However, the relationship between the serum Lp(a) and clinical outcomes has been seldom studied in Chinese hospitalized patients with cardiovascular diseases.

METHODS

We retrospectively collected the clinical data of hospitalized patients with cardiovascular diseases in the Cardiovascular Department of Dongguan People's Hospital from 2016 to 2021 through the electronic case system. Patients were divided into 4 groups based on Lp(a) quartiles: Quartile1 (≤ 80.00 mg/L), Quartile 2 (80.01 ~ 160.90 mg/L), Quartile 3 (160.91 ~ 336.41 mg/L), Quartile 4 (> 336.41 mg/L). Cox proportional hazard regression models were constructed to examine the relationship between Lp(a) and cardiovascular events.

RESULTS

A total of 8382 patients were included in this study. After an average follow-up of 619 (320 to 1061) days, 1361 (16.2%) patients developed major adverse cardiovascular events, and 125 (1.5%) all-cause death were collected. The incidence of MACEs was 7.65, 8.24, 9.73 and 10.75 per 100 person-years in each Lp(a) quartile, respectively; the all-cause mortality was 0.48, 0.69, 0.64 and 1.18 per 100 person-years in each Lp(a) quartile, respectively. The multivariate Cox regression analysis suggested that high Lp(a) level was an independent risk factor for MACEs (HR: 1.189, [95% CI: 1.045 to 1.353], P = 0.030) and all-cause death (HR: 1.573, [95% CI: 1.009 to 2.452], P = 0.046).

CONCLUSION

In addition to traditional lipid indicators, higher Lp(a) exhibited higher risks of adverse cardiovascular events and death, indicated worse prognosis. Lp(a) may be a new target for the prevention of atherosclerotic diseases.

Lipoprotein (a)-Related Inflammatory Imbalance: A Novel Horizon for the Development of Atherosclerosis

PURPOSE OF REVIEW

The primary objective of this review is to explore the pathophysiological roles and clinical implications of lipoprotein(a) [Lp(a)] in the context of atherosclerotic cardiovascular disease (ASCVD). We seek to understand how Lp(a) contributes to inflammation and arteriosclerosis, aiming to provide new insights into the mechanisms of ASCVD progression.

RECENT FINDINGS

Recent research highlights Lp(a) as an independent risk factor for ASCVD. Studies show that Lp(a) not only promotes the inflammatory processes but also interacts with various cellular components, leading to endothelial dysfunction and smooth muscle cell proliferation. The dual role of Lp(a) in both instigating and, under certain conditions, mitigating inflammation is particularly noteworthy. This review finds that Lp(a) plays a complex role in the development of ASCVD through its involvement in inflammatory pathways. The interplay between Lp(a) levels and inflammatory responses highlights its potential as a target for therapeutic intervention. These insights could pave the way for novel approaches in managing and preventing ASCVD, urging further investigation into Lp(a) as a therapeutic target.

Lipoprotein(a) as a cardiovascular risk factor among patients with and without diabetes Mellitus: the Mass General Brigham Lp(a) Registry

BACKGROUND

Diabetes mellitus (DM) and Lp(a) are well-established predictors of coronary artery disease (CAD) outcomes. However, their combined association remains poorly understood.

OBJECTIVE

To investigate the relationship between elevated Lp(a) and DM with CAD outcomes.

METHODS

Retrospective analysis of the MGB Lp(a) Registry involving patients ≥ 18 years who underwent Lp(a) measurements between 2000 and 2019. Exclusion criteria were severe kidney dysfunction, malignant neoplasms, and prior atherosclerotic cardiovascular disease (ASCVD). The primary outcome was a combination of cardiovascular death or myocardial infarction (MI). Elevated Lp(a) was defined as > 90th percentile (≥ 216 nmol/L).

RESULTS

Among 6,238 patients who met the eligibility criteria, the median age was 54, 45% were women, and 12% had DM. Patients with DM were older, more frequently male, and had a higher prevalence of additional cardiovascular risk factors. Over a median follow-up of 12.9 years, patients with either DM or elevated Lp(a) experienced higher rates of the primary outcome. Notably, those with elevated Lp(a) had a higher incidence of the primary outcome regardless of their DM status. The annual event rates were as follows: No-DM and Lp(a) < 90th% - 0.6%; No-DM and Lp(a) > 90th% - 1.3%; DM and Lp(a) < 90th% - 1.9%; DM and Lp(a) > 90th% - 4.7% (p < 0.001). After adjusting for confounders, elevated Lp(a) remained independently associated with the primary outcome among both patients with DM (HR = 2.66 [95%CI: 1.55-4.58], p < 0.001) and those without DM (HR = 2.01 [95%CI: 1.48-2.74], p < 0.001).

CONCLUSIONS

Elevated Lp(a) constitutes an independent and incremental risk factor for CAD outcomes in patients with and without DM.

Aortic Valve Calcium Score: Applications in Clinical Practice and Scientific Research-A Narrative Review

In this narrative review, we investigate the essential role played by the computed tomography Aortic Valve Calcium Score (AVCS) in the cardiovascular diagnostic landscape, with a special focus on its implications for clinical practice and scientific research. Calcific aortic valve stenosis is the most prevalent type of aortic stenosis (AS) in industrialized countries, and due to the aging population, its prevalence is increasing. While transthoracic echocardiography (TTE) remains the gold standard, AVCS stands out as an essential complementary tool in evaluating patients with AS. The advantage of AVCS is its independence from flow; this allows for a more precise evaluation of patients with discordant findings in TTE. Further clinical applications of AVCS include in the assessment of patients before transcatheter aortic valve replacement (TAVR), as it helps in predicting outcomes and provides prognostic information post-TAVR. Additionally, we describe different AVCS thresholds regarding gender and the anatomical variations of the aortic valve. Finally, we discuss various scientific studies where AVCS was applied. As AVCS has some limitations, due to the pathophysiologies of AS extending beyond calcification and gender differences, scientists strive to validate contrast-enhanced AVCS. Furthermore, research on developing radiation-free methods of measuring calcium content is ongoing.

Worldwide Increasing Use of Nonfasting Rather Than Fasting Lipid Profiles

BACKGROUND

Historically, lipids and lipoproteins were measured in the fasting state for cardiovascular risk prediction; however, since 2009 use of nonfasting lipid profiles has increased substantially worldwide. For patients, nonfasting lipid profiles are convenient and avoid any risk of hypoglycemia. For laboratories, blood sampling in the morning and extra visits for patients who have not fasted are avoided. For patients, clinicians, hospitals, and society, nonfasting sampling allows same-day visits with first blood sampling followed by a short wait for test results before clinical consultation. Therefore, nonfasting compared to fasting lipid profiles will save money and time and may improve patient compliance with cardiovascular prevention programs.

CONTENT

We report on the progression of endorsement and implementation of nonfasting lipid profiles for cardiovascular risk prediction worldwide and summarize the recommendations from major medical societies and health authorities in different countries. We also describe practical advantages and disadvantages for using nonfasting lipid profiles. Further, we include a description of why fasting has been the standard historically, the barriers against implementation of nonfasting lipid profiles, and finally we suggest the optimal content of a nonfasting lipid profile.

SUMMARY

Lipid, lipoprotein, and apolipoprotein concentrations vary minimally in response to normal food intake and nonfasting lipid profiles are equal or superior to fasting profiles for cardiovascular risk prediction. Major guidelines and consensus statements in Europe, the United States, Canada, Brazil, Japan, India, and Australia now endorse use of nonfasting lipid profiles in some or all patients; however, there are still gaps in endorsement and implementation of nonfasting lipid profiles worldwide.

Synergetic impact of lipoprotein(a) and fibrinogen on stroke in coronary artery disease patients

BACKGROUND

Emerging data suggested that lipoprotein(a) [Lp(a)] is an independent risk factor for atherosclerotic cardiovascular disease. Previous studies indicated fibrinogen (Fib) had synergetic effect on Lp(a)-induced events. However, combined impact of Fib and Lp(a) on ischemic stroke has not been elucidated.

METHODS

In this prospective study, we consecutively enrolled 8263 patients with stable coronary artery diseases (CAD) from 2011 to 2017. Patients were categorized into three groups according to tertiles of Lp(a) levels [Lp(a)-low, Lp(a)-medium, and Lp(a)-high] and further divided into nine groups by Lp(a) and Fib levels. All subjects were followed up for the occurrence of ischemic stroke.

RESULTS

During a median follow-up of 37.7 months, 157 (1.9%) ischemic strokes occurred. Stroke incidence increased by Lp(a) (1.1 vs. 2.1 vs. 2.5%, Cochran-Armitage p < .001) and Fib (1.1 vs. 2.0 vs. 2.6%, Cochran-Armitage p < .001) categories. When further classified into nine groups by Lp(a) and Fib levels, the incidence of ischemic stroke in group 9 [Lp(a)-high and Fib-high] was significantly higher than that in group 1 [Lp(a)-low and Fib-low] (3.1 vs. 6%, p < .001). The group 9 was associated with a highest risk for ischemic stroke (adjusted HR 4.907, 95% CI: 2.154-11.18, p < .001), compared with individuals in the Lp(a)-high (adjusted HR 2.290, 95% CI: 1.483-3.537, p < .001) or Fib-high (adjusted HR 1.184, 95% CI: 1.399-3.410, p = .001). Furthermore, combining Lp(a) with Fib increased C-statistics by .045 (p = .004).

CONCLUSIONS

Current study first demonstrated that elevated Lp(a) combining with Fib evaluation enhanced the risk of ischemic stroke in patients with CAD beyond Lp(a) or Fib alone.

Independent Relationship of Lipoprotein(a) and Carotid Atherosclerosis With Long-Term Risk of Cardiovascular Disease

BACKGROUND

Lipoprotein(a) (Lp(a)) is considered to be a causal risk factor of atherosclerotic cardiovascular disease (ASCVD), but whether there is an independent or joint association of Lp(a) and atherosclerotic plaque with ASCVD risk remains uncertain. This study aims to assess ASCVD risk independently or jointly conferred by Lp(a) and carotid atherosclerotic plaque.

METHODS AND RESULTS

A total of 5471 participants with no history of cardiovascular disease at baseline were recruited and followed up for ASCVD events (all fatal and nonfatal acute coronary and ischemic stroke events) over a median of 11.5 years. Independent association of Lp(a), or the joint association of Lp(a) and carotid plaque with ASCVD risk, was explored using Cox proportional hazards models. Overall, 7.6% of the participants (60.0±7.9 years of age; 2649 [48.4%] men) had Lp(a) ≥50 mg/dL, and 539 (8.4/1000 person-years) incident ASCVD events occurred. Lp(a) concentrations were independently associated with long-term risk of total ASCVD events, as well as coronary events and ischemic stroke events. Participants with Lp(a) ≥50 mg/dL had a 62% higher risk of ASCVD incidence (95% CI, 1.19-2.21) than those with Lp(a) <10 mg/dL, and they exhibited a 10-year ASCVD incidence of 11.7%. This association exists even after adjusting for prevalent plaque. Moreover, participants with Lp(a) ≥30 mg/dL and prevalent plaque had a significant 4.18 times higher ASCVD risk than those with Lp(a) <30 mg/dL and no plaque.

CONCLUSIONS

Higher Lp(a) concentrations are independently associated with long-term ASCVD risk and may exaggerate cardiovascular risk when concomitant with atherosclerotic plaque.

Association between lipoprotein(a) and premature atherosclerotic cardiovascular disease: a systematic review and meta-analysis

AIMS

High lipoprotein(a) [Lp(a)] level has been demonstrated as an important risk factor for atherosclerotic cardiovascular diseases (ASCVD) amongst the older populations, whereas its effects in the younger population remain unclear. This study evaluated the associations between Lp(a) and the risk of premature ASCVD.

METHOD AND RESULTS

PubMed and Embase were searched for related studies until 12 November 2023. Fifty-one studies including 100 540 participants were included. Mean age of patients ranged from 35.3 to 62.3 years. The proportion of male participants ranged from 0% to 100%. The mean follow-up was provided in five studies ranging from 1 year to 40 years. The definition of elevated Lp(a) varied among studies, such as >30 mg/dL, >50 mg/dL, the top tertiles, the top quartiles, the top quintiles, and so on. Higher Lp(a) was significantly associated with the composite ASCVD [odds ratio (OR): 2.15, 95% confidence interval (95% CI): 1.53-3.02, P < 0.001], especially for coronary artery disease (OR: 2.44, 95% CI: 2.06-2.90, P < 0.001) and peripheral arterial disease (OR: 2.56, 95% CI: 1.56-4.21, P < 0.001). This association remained significant in familial hypercholesterolaemia (FH) (OR: 3.11, 95% CI: 1.63-5.96, P < 0.001) and type 2 diabetes mellitus (T2DM) patients (OR: 2.23; 95% CI: 1.54-3.23, P < 0.001).Significant results were observed in South Asians (OR: 3.71, 95% CI: 2.31-5.96, P < 0.001), Caucasians (OR: 3.17, 95% CI: 2.22-4.52, P < 0.001), and patients with baseline low-density lipoprotein cholesterol (LDL-c) level ≥ 2.6 mmol/L.

CONCLUSION

Elevated Lp(a) predicts the risk of the composite or individual ASCVD in young, regardless of study design, gender, population characteristics (community or hospitalized), different premature definitions, and various Lp(a) measurement approaches. This association was important in South Asians, Caucasians, FH patients, T2DM patients, and patients with baseline LDL-c level ≥ 2.6 mmol/L.

Lipoprotein(a) is associated with recurrent cardiovascular events in patients with coronary artery disease and prediabetes or diabetes

PURPOSE

Elevated lipoprotein(a) [Lp(a)] and diabetes mellitus (DM) are both associated with adverse events in high-risk patients with established coronary artery disease (CAD). Currently, the association between Lp(a) levels and recurrent cardiovascular (CV) events (CVEs) remained undetermined in patients with different glucose status. Therefore, this study aimed to investigate the prognostic significance of Lp(a) levels for recurrent CVEs in high-risk CAD patients who suffered from first CVEs according to different glycemic metabolism.

METHODS

We recruited 5257 consecutive patients with prior CVEs and followed up for recurrent CVEs, including CV death, non-fatal myocardial infarction (MI), and non-fatal stroke. Patients were assigned to low, medium, and high groups according to Lp(a) levels and further stratified by glucose status.

RESULTS

During a median 37-month follow-up, 225 (4.28%) recurrent CVEs occurred. High Lp(a) was independently associated with recurrent CVEs [adjusted Hazard Ratio (HR), 1.57; 95% confidence interval (CI) 1.12-2.19; P = 0.008]. When participants were classified according to Lp(a) levels and glycemic status, high Lp(a) levels were associated with an increased risk of recurrent CVEs in pre-DM (adjusted HR, 2.96; 95% CI 1.24-7.05; P = 0.014). Meanwhile, medium and high Lp(a) levels were both associated with an increased risk for recurrent CVEs in DM (adjusted HR, 3.09; 95% CI 1.30-7.34; P = 0.010 and adjusted HR, 3.13, 95% CI 1.30-7.53; P = 0.011, respectively).

CONCLUSIONS

This study demonstrated that elevated Lp(a) levels were associated with an increased recurrent CVE risk in patients with CAD, particularly among those with pre-DM and DM, indicating that Lp(a) may provide incremental value in risk stratification in this population.

Impact of lipoprotein(a) and fibrinogen on prognosis in patients with coronary artery disease: A retrospective cohort study

BACKGROUND

Despite the considerable progress made in preventative methods, medication, and interventional therapies, it remains evident that cardiovascular events (CVEs) continue to be the primary cause of both death and morbidity among individuals diagnosed with coronary artery disease (CAD).

OBJECTIVE

To compare the connection between lipoprotein a (Lp[a]), fibrinogen (Fib), and both parameters combined with all-cause mortality to detect their value as prognostic biomarkers.

METHODS

This is a retrospective study. Patients diagnosed with CAD between January 2007 and December 2020 at the Guangdong Provincial People's Hospital (China) were involved in the study. 43,367 patients met the eligibility criteria. The Lp(a) and Fib levels were distributed into three tertile groups (low, medium, and high). All of the patients included in the study were followed up for all-cause mortality. Kaplan-Meier and Cox regression were performed to determine the relationship between Lp(a), Fib, and all-cause mortality. A concordance statistics model was developed to detect the impact of Fib and Lp(a) in terms of anticipating poor outcomes in patients with CAD.

RESULTS

Throughout a median follow-up of 67.0 months, 6,883 (15.9%) patients died. Participants with high Lp(a) (above 27.60 mg/dL) levels had a significantly higher risk for all-cause mortality than individuals with low Lp(a) levels (below 11.13 mg/dL; adjusted hazard ratio [aHR] 1.219, 95% confidence interval [CI]: 1.141-1.304, p< 0.001). Similarly, patients with high Fib levels (above 4.32 g/L) had a significantly greater risk of developing all-cause mortality compared with those with reduced Fib levels (below 3.41 g/L; aHR 1.415, 95% CI: 1.323-1.514, p< 0.001). Patients with raised Lp(a) and Fib levels had the maximum risk for all-cause mortality (aHR 1.702; 95% CI: 1.558-1.859, p< 0.001). When considered together, Lp(a) and Fib caused a significant elevation of the concordance statistic by 0.009 (p< 0.05), suggesting a higher value for predicting mortality when combining the two indicators.

CONCLUSION

High Lp(a) and Fib levels could be used as predictive biomarkers for all-cause mortality in individuals with CAD. The prediction accuracy for all-cause mortality improved after combining the two parameters.

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.

Landscape of Statin as a Cornerstone in Atherosclerotic Cardiovascular Disease

Atherosclerosis, the key pathogenesis of cardiovascular disease, is a leading cause of death and disability worldwide. Statins are first-line lipid-lowering drugs, which have been demonstrated to be powerful agents for anti-atherosclerosis. Numerous studies have confirmed the cardiovascular benefits and long-term safety of statins in a wide range of patients. Statins play an indispensable and irreplaceable part in the prevention and treatment of atherosclerotic cardiovascular disease (ASCVD). In this article, we summarize the evolution of statins and their role in the treatment of cholesterol. The anti-atherosclerotic mechanism of statins, its efficacy, safety and clinical outcomes in secondary and primary prevention of ACSVD in different patient populations, the combination treatment effects, and guideline recommendations are also detailed. This paper highlights the profound significance of statins as the most successful anti-atherogenic drug in the cardiovascular field.

Acute effect of proprotein convertase subtilisin/kexin type 9 inhibitor on oxidized low-density lipoprotein and lipid profile in patients at cardiovascular risk

Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors are a new class of potent lipid-lowering drugs. Oxidized low-density lipoprotein (ox-LDL) is the key pathogenic factor leading to atherosclerosis. However, its effect on ox-LDL levels has not been clinically reported. The clinical data of 290 very high-risk atherosclerotic cardiovascular disease (ASCVD) patients diagnosed in the First Affiliated Hospital of Zhengzhou University from May 2022 to October 2022 were collected retrospectively. According to whether evolocumab (a PCSK9 inhibitor) was used after percutaneous coronary intervention (PCI), they were divided into evolocumab group (153 cases) and statin monotherapy group (137 cases). At hospital admission, ox-LDL, total cholesterol (TC), triglycerides (TG), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), apolipoproteinA1 (apoA1), apolipoprotein B-100 (apoB), lipoprotein (a) [Lp(a)], and high-sensitivity reactive protein (hs-CRP) levels were collected and used as baseline data. After two weeks of treatment, ox-LDL in the evolocumab group and statin monotherapy group were significantly lower than those before treatment (p<0.05). The decrease of ox-LDL in the evolocumab group was more than in the stain monotherapy group (p<0.05). In conclusion, PCSK9 inhibitors reduce ox-LDL levels in very high-risk ASCVD patients in a short time.

2023 China Guidelines for Lipid Management

Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of death among urban and rural residents in China, and elevated low-density lipoprotein cholesterol (LDL-C) is a risk factor for ASCVD. Considering the increasing burden of ASCVD, lipid management is of the utmost importance. In recent years, research on blood lipids has made breakthroughs around the world, hence a revision of China guidelines for lipid management is imperative, especially since the target lipid levels in the general population vary in respect to the risk of ASCVD. The level of LDL-C, which can be regarded as appropriate in a population without frisk factors, can be considered abnormal in people at high risk of developing ASCVD. As a result, the "Guidelines for the prevention and treatment of dyslipidemia" were adapted into the "China Guidelines for Lipid Management" (henceforth referred to as the new guidelines) by an Experts' committee after careful deliberation. The new guidelines still recommend LDL-C as the primary target for lipid control, with CVD risk stratification to determine its target value. These guidelines recommend that moderate intensity statin therapy in adjunct with a heart-healthy lifestyle, be used as an initial line of treatment, followed by cholesterol absorption inhibitors or/and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, as necessary. The new guidelines provide guidance for lipid management across various age groups, from children to the elderly. The aim of these guidelines is to comprehensively improve the management of lipids and promote the prevention and treatment of ASCVD by guiding clinical practice.

2023 Chinese guideline for lipid management

Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of death among urban and rural residents in China, and elevated low-density lipoprotein cholesterol (LDL-C) is a risk factor for ASCVD. Considering the increasing burden of ASCVD, lipid management is of the utmost importance. In recent years, research on blood lipids has made breakthroughs around the world, hence a revision of Chinese guideline for lipid management is imperative, especially since the target lipid levels in the general population vary in respect to the risk of ASCVD. The level of LDL-C, which can be regarded as appropriate in a population without frisk factors, can be considered abnormal in people at high risk of developing ASCVD. As a result, the "Guidelines for the prevention and treatment of dyslipidemia" were adapted into the "Chinese guideline for Lipid Management" (henceforth referred to as the new guidelines) by an Experts' committee after careful deliberation. The new guidelines still recommend LDL-C as the primary target for lipid control, with cardiovascular disease (CVD) risk stratification to determine its target value. These guidelines recommend that moderate intensity statin therapy in adjunct with a heart-healthy lifestyle, be used as an initial line of treatment, followed by cholesterol absorption inhibitors or/and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, as necessary. The new guidelines provide guidance for lipid management across various age groups, from children to the elderly. The aim of these guidelines is to comprehensively improve the management of lipids and promote the prevention and treatment of ASCVD by guiding clinical practice.

Prevalence, awareness, treatment, and control of dyslipidemia in Chinese adults: a systematic review and meta-analysis

Background

Researchers have conducted a considerable number of epidemiological studies on dyslipidemia in China over recent years. Nevertheless, a representative study to comprehensively appraise for the epidemiological status of dyslipidemia is still lacked. This meta-analysis is intended to explore the pooled prevalence, rates of awareness, treatment, and control of dyslipidemia among adults in Chinese Mainland.

Materials and methods

A systematic review was performed on relevant cross-sectional studies published since January 2012 by searching six authoritative literature databases. Meta-analyses were conducted in included studies based on a random-effect model to summarize the epidemiological status of dyslipidemia in China. A potential source of heterogeneity was detected by subgroup analysis and meta-regression. Publication bias was assessed by Egger's test and funnel plots. A sensitivity analysis was conducted to examine the study quality's influence on the pooled estimate of prevalence and rates of awareness, treatment, and control.

Results

Forty-one original researches with a total of 1,310,402 Chinese participants were finally included in the meta-analysis. The prevalence, rates of awareness, treatment, and control of dyslipidemia were 42.1%, 18.2%, 11.6%, and 5.4%, respectively. With a pooled prevalence estimate at 24.5%, low HDL-C was the most prevalent among various dyslipidemia types, followed by hypertriglyceridemia (TG) (15.4%), hypercholesterolemia (TC) (8.3%), and high LDL-C (7.1%). The pooled prevalence of elevated serum lipoprotein(a) [Lp(a)] was 19.4%. By gender, the prevalence of dyslipidemia was 47.3% in males and 38.8% in females. Subgroup analyses revealed that the prevalence in southern and urban areas were higher than their counterparts. Females and population in urban areas tended to possess higher rates of awareness, treatment, and control. Meta-regression analyses suggested that the year of screening influenced prevalence estimates for dyslipidemia. The impact of the study's quality on the pooled estimates is insignificant.

Conclusion

Our study suggested a severe epidemic situation of dyslipidemia among adults in Chinese Mainland. More importantly, the awareness, treatment, and control rates were extremely low, revealing that dyslipidemia is a grave health issue. Consequently, we should attach more importance to the management of dyslipidemia, especially in economically underdeveloped areas.

Systematic review registration

PROSPERO [CRD42022366456].

The Association of Lipoprotein(a) and Neutrophil-to-Lymphocyte Ratio Combination with Atherosclerotic Cardiovascular Disease in Chinese Patients

Objective

The association of lipoprotein(a) [Lp(a)] with atherosclerotic cardiovascular disease (ASCVD) risk can be modified by chronic systemic inflammation. The neutrophil-to-lymphocyte ratio (NLR) is a reliable and easily available marker of immune response to various infectious and non-infectious stimuli. The purpose of this study was to assess the combined effects of Lp(a) and NLR in predicting the ASCVD risk and coronary artery plaque traits.

Methods

This study included 1618 patients who had coronary computed tomography angiography (CTA) with risk assessment of ASCVD. CTA was used to evaluate the traits of coronary atherosclerotic plaques, and the association of ASCVD with Lp(a) and NLR was assessed by multivariate logistic regression models.

Results

Plasma Lp(a) and NLR were significantly increased in patients having plaques. High Lp(a) was defined as the plasma Lp(a) level > 75 nmol/L and high NLR as NLR > 1.686. The patients were grouped into four categories according to normal or high NLR and plasma Lp(a) as nLp(a)/NLR-, hLp(a)/NLR-, nLp(a)/NLR+ and hLp(a)/NLR+. The patients in the latter three groups had higher risk of ASCVD compared to the reference group nLp(a)/NLR-, with the highest ASCVD risk in the hLp(a)/NLR+ group (OR = 2.39, 95% CI = 1.49-3.83, P = 0.000). The occurrence of unstable plaques was 29.94% in the hLp(a)/NLR+ group, which was significantly higher than groups nLp(a)/NLR+, hLp(a)/NLR- and nLp(a)/NLR- with 20.83%, 26.54% and 22.58%, respectively, and there was a significantly increased risk of unstable plaque in the hLp(a)/NLR+ group compared to the nLp(a)/NLR- group (OR = 1.67, 95% CI = 1.04-2.68, P = 0.035). The risk of stable plaque was not significantly increased in the hLp(a)/NLR+ group compared to the nLp(a)/NLR- group (OR = 1.73, 95% CI = 0.96-3.10, P = 0.066).

Conclusion

The concomitant presence of elevated Lp(a) and higher NLR is associated with increased unstable coronary artery plaques in patients with ASCVD.

Lipoprotein(a) in clinical practice: A guide for the clinician

Cardiovascular disease (CVD) remains the leading cause of death worldwide. Serum lipoprotein(a) (Lp(a)) has been shown to be an independent and causative risk factor for atherosclerotic CVD and calcific aortic valvular disease. Lp(a) continues to be studied, with emerging insights into the epidemiology of CVD with respect to Lp(a), pathogenic mechanisms of Lp(a) and strategies to mitigate disease. There have been novel insights into genetic polymorphisms of the LPA gene, interactions between concomitant risk factors and Lp(a) based on real-world data, and metabolic pathway targets for Lp(a) reduction. This review highlights these recent advances in our understanding of Lp(a) and discusses management strategies as recommended by cardiovascular professional societies, emerging therapies for lowering Lp(a), and future directions in targeting Lp(a) to reduce CVD.

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.

Lipoprotein(a) distribution and its association with carotid arteriopathy in the Chinese population

BACKGROUND AND AIMS

The distribution of lipoprotein(a) [Lp(a)] has not been well-studied in a large population in China. The relationship between Lp(a) and carotid atherosclerosis remains undefined. In this study, we aimed to investigate the distribution of Lp(a) levels and to assess their association with carotid arteriopathy in China.

METHODS

In this cross-sectional study, 411,634 adults with Lp(a) measurements from 22 health check-up centers were used to investigate Lp(a) distribution in China. Among participants with Lp(a) data, carotid ultrasound was performed routinely at seven health check-up centers covering 75,305 subjects. Carotid intima-media thickness (cIMT) and carotid plaque were used as surrogate biomarkers of carotid arteriopathy. The multivariate logistic regression model was applied to evaluate the association of increased Lp(a) levels with carotid arteriopathy.

RESULTS

The distribution of Lp(a) concentrations was right-skewed, with a median concentration of 10.60 mg/dL. The proportions of Lp(a) levels ≥30 mg/dL and ≥50 mg/dL were 16.75% and 7.10%, respectively. The median Lp(a) level was higher in females individuals in northern China, and increased with age. Spearman's analysis revealed weak correlations between the Lp(a) concentration as a continuous variable and other lipid profiles. The multiple logistic regression analysis showed that participants with Lp(a) levels ≥50 mg/dL had an increased risk of cIMT ≥1.0 mm (OR = 1.138, 95% CI, 1.071-1.208) and carotid plaque (OR = 1.296, 95% CI, 1.219-1.377) compared with those with Lp(a) levels <50 mg/dL.

CONCLUSIONS

This is the first study of the Lp(a) distribution in a large population in China. Our findings revealed a positive association between elevated Lp(a) levels (≥50 mg/dL) and increased prevalence of carotid atherosclerosis, which implies an increased risk of cardiovascular disease in the future.

Lipoprotein(a) Is Associated With the Progression and Vulnerability of New-Onset Carotid Atherosclerotic Plaque

BACKGROUND

Although important progress has been made in understanding Lp(a) (lipoprotein[a])-mediated stroke risk, the contribution of Lp(a) to the progression of vulnerable plaque features associated with stroke risk remains unclear. This study aims to evaluate whether Lp(a) is associated with carotid plaque progression, new-onset plaque features, and plaque vulnerability in a prospective community-based cohort study.

METHODS

Baseline Lp(a) levels were measured using latex-enhanced turbidimetric immunoassay among 804 participants aged 45 to 74 years and free of cardiovascular disease in the Chinese Multi-provincial Cohort Study-Beijing project. Carotid atherosclerosis was measured twice by B-mode ultrasonography over a 10-year interval during the 2002 and 2012 surveys to assess the progression of total, vulnerable and stable plaques, and plaque vulnerability. The total plaque area and plaque vulnerability score were calculated.

RESULTS

The median baseline Lp(a) level was 10.20 mg/dL (interquartile range, 6.20 to 17.18 mg/dL). Modified Poisson regression analysis showed that Lp(a) ≥50 mg/dL was significantly associated with 10-year progression of total carotid plaque (relative risk [RR], 1.41 [95% CI, 1.21-1.64]; E-value=2.17), vulnerable plaque (RR, 1.93 [95% CI, 1.54-2.41]), and stable plaque (RR, 1.51 [95% CI, 1.11-2.07]) compared with Lp(a) <50 mg/dL. Moreover, among participants without plaque at baseline, Lp(a) ≥50 mg/dL was related to an increased total plaque area (β=0.36 [95% CI, 0.06-0.65]; P=0.018) and increased plaque vulnerability score (β=0.30 [95% CI, 0.01-0.60]; P=0.045) in multivariable linear regression.

CONCLUSIONS

Elevated Lp(a) levels were associated with 10-year carotid plaque progression and plaque vulnerability, providing a basis for Lp(a) as a treatment target for stroke prevention.

Exploring the role of lipoprotein(a) in cardiovascular diseases and diabetes in Chinese population

A high level of lipoprotein (a) in the plasma has been associated with a variety of cardiovascular diseases and is considered to be an independent predictor of some other diseases. Based on recent studies, the concentration levels of Lp(a) in the Chinese population exhibit a distinctive variation from other populations. In the Chinese population, a high level of Lp(a) indicates a higher incidence of revascularization, platelet aggregation, and thrombogenicity following PCI. Increased risk of atherosclerotic cardiovascular disease (ASCVD) in Chinese population has been linked to higher levels of Lp(a), according to studies. More specifically, it has been found that in Chinese populations, higher levels of Lp(a) were linked to an increased risk of coronary heart disease, severe aortic valve stenosis, deep vein thrombosis in patients with spinal cord injuries, central vein thrombosis in patients receiving hemodialysis, and stroke. Furthermore, new and consistent data retrieved from several clinical trials also suggest that Lp (a) might also play an essential role in some other conditions, including metabolic syndrome, type 2 diabetes and cancers. This review explores the clinical and epidemiological relationships among Lp(a), cardiovascular diseases and diabetes in the Chinese population as well as potential Lp(a) underlying mechanisms in these diseases. However, further research is needed to better understand the role of Lp(a) in cardiovascular diseases and especially diabetes in the Chinese population.