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Koschinsky ML, Bajaj A, Boffa MB, Dixon DL, Ferdinand KC, Gidding SS, Gill EA, Jacobson TA, Michos ED, Safarova MS, Soffer DE, Taub PR, Wilkinson MJ, Wilson DP, Ballantyne CM. A focused update to the 2019 NLA scientific statement on use of lipoprotein(a) in clinical practice. J Clin Lipidol 2024:S1933-2874(24)00033-3. [PMID: 38565461 DOI: 10.1016/j.jacl.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 03/06/2024] [Indexed: 04/04/2024]
Abstract
Since the 2019 National Lipid Association (NLA) Scientific Statement on Use of Lipoprotein(a) in Clinical Practice was issued, accumulating epidemiological data have clarified the relationship between lipoprotein(a) [Lp(a)] level and cardiovascular disease risk and risk reduction. Therefore, the NLA developed this focused update to guide clinicians in applying this emerging evidence in clinical practice. We now have sufficient evidence to support the recommendation to measure Lp(a) levels at least once in every adult for risk stratification. Individuals with Lp(a) levels <75 nmol/L (30 mg/dL) are considered low risk, individuals with Lp(a) levels ≥125 nmol/L (50 mg/dL) are considered high risk, and individuals with Lp(a) levels between 75 and 125 nmol/L (30-50 mg/dL) are at intermediate risk. Cascade screening of first-degree relatives of patients with elevated Lp(a) can identify additional individuals at risk who require intervention. Patients with elevated Lp(a) should receive early, more-intensive risk factor management, including lifestyle modification and lipid-lowering drug therapy in high-risk individuals, primarily to reduce low-density lipoprotein cholesterol (LDL-C) levels. The U.S. Food and Drug Administration approved an indication for lipoprotein apheresis (which reduces both Lp(a) and LDL-C) in high-risk patients with familial hypercholesterolemia and documented coronary or peripheral artery disease whose Lp(a) level remains ≥60 mg/dL [∼150 nmol/L)] and LDL-C ≥ 100 mg/dL on maximally tolerated lipid-lowering therapy. Although Lp(a) is an established independent causal risk factor for cardiovascular disease, and despite the high prevalence of Lp(a) elevation (∼1 of 5 individuals), measurement rates are low, warranting improved screening strategies for cardiovascular disease prevention.
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Affiliation(s)
- Marlys L Koschinsky
- Department of Physiology & Pharmacology and Robarts Research Institute, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada (Drs Koschinsky, Boffa)
| | - Archna Bajaj
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA (Drs Bajaj, Soffer)
| | - Michael B Boffa
- Department of Physiology & Pharmacology and Robarts Research Institute, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada (Drs Koschinsky, Boffa)
| | - Dave L Dixon
- Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, VA, USA (Dr Dixon)
| | - Keith C Ferdinand
- Department of Medicine, Tulane University School of Medicine, New Orleans, LA, USA (Dr. Ferdinand)
| | - Samuel S Gidding
- Department of Genomic Health, Geisinger. Danville, PA, USA (Dr Gidding)
| | - Edward A Gill
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA (Dr Gill)
| | - Terry A Jacobson
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA (Dr Jacobson)
| | - Erin D Michos
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA (Dr Michos)
| | - Maya S Safarova
- Division of Cardiovascular Medicine, Department of Internal Medicine, Froedtert & the Medical College of Wisconsin, Milwaukee, WI, USA (Dr Safarova)
| | - Daniel E Soffer
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA (Drs Bajaj, Soffer)
| | - Pam R Taub
- Department of Medicine, University of California San Diego, La Jolla, CA, USA (Drs Taub, Wilkinson)
| | - Michael J Wilkinson
- Department of Medicine, University of California San Diego, La Jolla, CA, USA (Drs Taub, Wilkinson)
| | - Don P Wilson
- Department of Pediatric Endocrinology and Diabetes, Cook Children's Medical Center, Fort Worth, TX, USA (Dr Wilson)
| | - Christie M Ballantyne
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA (Dr Ballantyne).
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Higgins V, White-Al Habeeb NMA, Bailey D, Beriault DR, Blasutig IM, Collier CP, Venner AA, Adeli K. Canadian Society of Clinical Chemists Harmonized Pediatric Lipid Reporting Recommendations for Clinical Laboratories. Can J Cardiol 2024:S0828-282X(24)00071-0. [PMID: 38336003 DOI: 10.1016/j.cjca.2024.01.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 12/20/2023] [Accepted: 01/07/2024] [Indexed: 02/12/2024] Open
Abstract
Detecting dyslipidemia early is important because atherosclerosis originates in childhood and early treatment can improve outcomes. In 2022, the Canadian Cardiovascular Society (CCS)/Canadian Pediatric Cardiology Association (CPCA) published a clinical practice update to detect, evaluate, and manage pediatric dyslipidemia. However, guidance on its translation into clinical laboratories is lacking. The Canadian Society of Clinical Chemists Working Group on Reference Interval Harmonization Lipid Team aims to assist guideline implementation and promote harmonized pediatric lipid reporting across Canada. The 2022 CCS/CPCA clinical practice update, 2011 National Heart, Lung, and Blood Institute integrated guidelines, and new data analysis (Canadian pediatric reference values from the Canadian Laboratory Initiative on Pediatric Reference Intervals [CALIPER] and retrospective patient data from large community laboratories) were incorporated to develop 5 key recommendations. These include recommendations to: (1) offer nonfasting and fasting lipid testing; (2) offer a lipid panel including total cholesterol, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), non-HDL-C, and triglycerides, with apolipoprotein B and lipoprotein(a) available as individually orderable tests; (3) flag total cholesterol, LDL-C, and non-HDL-C results ≥ 95th percentile, and HDL-C results < 10th percentile, as recommended by CCS/CPCA/National Heart, Lung, and Blood Institute and validated by CALIPER, and flag apolipoprotein B and nonfasting triglyceride results ≥ 95th percentile on the basis of CALIPER, and do not flag lipoprotein(a) results but mention the adult cutoff in the interpretive comments; (4) implement interpretive comments listed in the current report; and (5) implement the National Institutes of Health LDL-C equation. The Canadian Society of Clinical Chemists Working Group on Reference Interval Harmonization Lipid Team will support clinical laboratories to implement these recommendations using knowledge translation strategies. Harmonizing pediatric lipid reporting across Canadian clinical laboratories will optimize clinical decision-making and improve cardiovascular risk management in youth.
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Affiliation(s)
- Victoria Higgins
- DynaLIFE Medical Labs, Edmonton, Alberta, Canada; Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | | | | | - Daniel R Beriault
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada; Department of Laboratory Medicine and Pathobiology, St Michael's Hospital, Toronto, Ontario, Canada
| | - Ivan M Blasutig
- Eastern Ontario Regional Laboratory Association, Ottawa, Ontario, Canada; Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada; Department of Pathology and Laboratory Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Christine P Collier
- Pathology and Laboratory Medicine, Royal Columbian Hospital, New Westminster, British Columbia, Canada; Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Allison A Venner
- Alberta Precision Laboratories, Calgary, Alberta, Canada; Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Khosrow Adeli
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada; Department of Pediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.
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3
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Marcovina SM. Lipoprotein(a): a genetically determined risk factor for Cardiovascular disease. Crit Rev Clin Lab Sci 2023; 60:560-572. [PMID: 37452525 DOI: 10.1080/10408363.2023.2229915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 05/11/2023] [Accepted: 06/22/2023] [Indexed: 07/18/2023]
Abstract
Lipoprotein(a) is a complex lipoprotein with unique characteristics distinguishing it from all the other apolipoprotein B-containing lipoprotein particles. Its lipid composition and the presence of a single molecule of apolipoprotein B per particle, render lipoprotein(a) similar to low-density lipoproteins. However, the presence of a unique, carbohydrate-rich protein termed apolipoprotein(a), linked by a covalent bond to apolipoprotein B imparts unique characteristics to lipoprotein(a) distinguishing it from all the other lipoproteins. Apolipoprotein(a) is highly polymorphic in size ranging in molecular weight from <300 KDa to >800 kDa. Both the size polymorphism and the concentration of lipoprotein(a) in plasma are genetically determined and unlike other lipoproteins, plasma concentration is minimally impacted by lifestyle modifications or lipid-lowering drugs. Many studies involving hundreds of thousands of individuals have provided strong evidence that elevated lipoprotein(a) is genetically determined and a causal risk factor for atherosclerotic cardiovascular disease. The concentration attained in adulthood is already present in children at around 5 years of age and therefore, those with elevated lipoprotein(a) are prematurely exposed to a high risk of cardiovascular disease. Despite the large number of guidelines and consensus statements on the management of lipoprotein(a) in atherosclerotic cardiovascular disease published in the last decade, lipoprotein(a) is still seldom measured in clinical settings. In this review, we provide an overview of the most important features that characterize lipoprotein(a), its role in cardiovascular disease, and the importance of adding the measurement of lipoprotein(a) for screening adults and youths to identify those at increased risk of atherosclerotic cardiovascular disease due to their elevated plasma concentration of lipoprotein(a).
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Brosolo G, Da Porto A, Marcante S, Picci A, Capilupi F, Capilupi P, Bulfone L, Vacca A, Bertin N, Vivarelli C, Comand J, Catena C, Sechi LA. Lipoprotein(a): Just an Innocent Bystander in Arterial Hypertension? Int J Mol Sci 2023; 24:13363. [PMID: 37686169 PMCID: PMC10487946 DOI: 10.3390/ijms241713363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 08/25/2023] [Accepted: 08/25/2023] [Indexed: 09/10/2023] Open
Abstract
Elevated plasma lipoprotein(a) [Lp(a)] is a relatively common and highly heritable trait conferring individuals time-dependent risk of developing atherosclerotic cardiovascular disease (CVD). Following its first description, Lp(a) triggered enormous scientific interest in the late 1980s, subsequently dampened in the mid-1990s by controversial findings of some prospective studies. It was only in the last decade that a large body of evidence has provided strong arguments for a causal and independent association between elevated Lp(a) levels and CVD, causing renewed interest in this lipoprotein as an emerging risk factor with a likely contribution to cardiovascular residual risk. Accordingly, the 2022 consensus statement of the European Atherosclerosis Society has suggested inclusion of Lp(a) measurement in global risk estimation. The development of highly effective Lp(a)-lowering drugs (e.g., antisense oligonucleotides and small interfering RNA, both blocking LPA gene expression) which are still under assessment in phase 3 trials, will provide a unique opportunity to reduce "residual cardiovascular risk" in high-risk populations, including patients with arterial hypertension. The current evidence in support of a specific role of Lp(a) in hypertension is somehow controversial and this narrative review aims to overview the general mechanisms relating Lp(a) to blood pressure regulation and hypertension-related cardiovascular and renal damage.
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Affiliation(s)
- Gabriele Brosolo
- Department of Medicine, University of Udine, 33100 Udine, Italy; (A.D.P.); (S.M.); (A.P.); (F.C.); (P.C.); (L.B.); (A.V.); (N.B.); (C.V.); (J.C.); (C.C.)
- European Hypertension Excellence Center, Clinica Medica, University of Udine, 33100 Udine, Italy
| | - Andrea Da Porto
- Department of Medicine, University of Udine, 33100 Udine, Italy; (A.D.P.); (S.M.); (A.P.); (F.C.); (P.C.); (L.B.); (A.V.); (N.B.); (C.V.); (J.C.); (C.C.)
- Diabetes and Metabolism Unit, Clinica Medica, University of Udine, 33100 Udine, Italy
| | - Stefano Marcante
- Department of Medicine, University of Udine, 33100 Udine, Italy; (A.D.P.); (S.M.); (A.P.); (F.C.); (P.C.); (L.B.); (A.V.); (N.B.); (C.V.); (J.C.); (C.C.)
- European Hypertension Excellence Center, Clinica Medica, University of Udine, 33100 Udine, Italy
| | - Alessandro Picci
- Department of Medicine, University of Udine, 33100 Udine, Italy; (A.D.P.); (S.M.); (A.P.); (F.C.); (P.C.); (L.B.); (A.V.); (N.B.); (C.V.); (J.C.); (C.C.)
- European Hypertension Excellence Center, Clinica Medica, University of Udine, 33100 Udine, Italy
| | - Filippo Capilupi
- Department of Medicine, University of Udine, 33100 Udine, Italy; (A.D.P.); (S.M.); (A.P.); (F.C.); (P.C.); (L.B.); (A.V.); (N.B.); (C.V.); (J.C.); (C.C.)
- European Hypertension Excellence Center, Clinica Medica, University of Udine, 33100 Udine, Italy
| | - Patrizio Capilupi
- Department of Medicine, University of Udine, 33100 Udine, Italy; (A.D.P.); (S.M.); (A.P.); (F.C.); (P.C.); (L.B.); (A.V.); (N.B.); (C.V.); (J.C.); (C.C.)
- European Hypertension Excellence Center, Clinica Medica, University of Udine, 33100 Udine, Italy
| | - Luca Bulfone
- Department of Medicine, University of Udine, 33100 Udine, Italy; (A.D.P.); (S.M.); (A.P.); (F.C.); (P.C.); (L.B.); (A.V.); (N.B.); (C.V.); (J.C.); (C.C.)
- European Hypertension Excellence Center, Clinica Medica, University of Udine, 33100 Udine, Italy
| | - Antonio Vacca
- Department of Medicine, University of Udine, 33100 Udine, Italy; (A.D.P.); (S.M.); (A.P.); (F.C.); (P.C.); (L.B.); (A.V.); (N.B.); (C.V.); (J.C.); (C.C.)
- European Hypertension Excellence Center, Clinica Medica, University of Udine, 33100 Udine, Italy
| | - Nicole Bertin
- Department of Medicine, University of Udine, 33100 Udine, Italy; (A.D.P.); (S.M.); (A.P.); (F.C.); (P.C.); (L.B.); (A.V.); (N.B.); (C.V.); (J.C.); (C.C.)
- Thrombosis and Hemostasis Unit, Clinica Medica, University of Udine, 33100 Udine, Italy
| | - Cinzia Vivarelli
- Department of Medicine, University of Udine, 33100 Udine, Italy; (A.D.P.); (S.M.); (A.P.); (F.C.); (P.C.); (L.B.); (A.V.); (N.B.); (C.V.); (J.C.); (C.C.)
| | - Jacopo Comand
- Department of Medicine, University of Udine, 33100 Udine, Italy; (A.D.P.); (S.M.); (A.P.); (F.C.); (P.C.); (L.B.); (A.V.); (N.B.); (C.V.); (J.C.); (C.C.)
- European Hypertension Excellence Center, Clinica Medica, University of Udine, 33100 Udine, Italy
| | - Cristiana Catena
- Department of Medicine, University of Udine, 33100 Udine, Italy; (A.D.P.); (S.M.); (A.P.); (F.C.); (P.C.); (L.B.); (A.V.); (N.B.); (C.V.); (J.C.); (C.C.)
- European Hypertension Excellence Center, Clinica Medica, University of Udine, 33100 Udine, Italy
| | - Leonardo A. Sechi
- Department of Medicine, University of Udine, 33100 Udine, Italy; (A.D.P.); (S.M.); (A.P.); (F.C.); (P.C.); (L.B.); (A.V.); (N.B.); (C.V.); (J.C.); (C.C.)
- European Hypertension Excellence Center, Clinica Medica, University of Udine, 33100 Udine, Italy
- Diabetes and Metabolism Unit, Clinica Medica, University of Udine, 33100 Udine, Italy
- Thrombosis and Hemostasis Unit, Clinica Medica, University of Udine, 33100 Udine, Italy
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Krittanawong C, Maitra NS, El-Sherbini AH, Shah N, Lavie CJ, Shapiro MD, Virani SS. Lipoprotein(a) in clinical practice: A guide for the clinician. Prog Cardiovasc Dis 2023; 79:28-36. [PMID: 37516261 DOI: 10.1016/j.pcad.2023.07.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 07/26/2023] [Indexed: 07/31/2023]
Abstract
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.
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Affiliation(s)
- Chayakrit Krittanawong
- Cardiology Division, NYU Langone Health and NYU School of Medicine, New York, NY, United States of America.
| | - Neil Sagar Maitra
- Division of Cardiology, Scripps Clinic, La Jolla, CA, United States of America
| | - Adham H El-Sherbini
- Faculty of Health Sciences, Queen's University, Kingston, ON K7L 3N6, Canada
| | - Nishant Shah
- Division of Cardiology, Duke Heart Center, Duke University, 2301 Erwin RD, Durham, NC, United States of America
| | - Carl J Lavie
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, LA, United States of America
| | - Michael D Shapiro
- Section on Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, United States of America; Center for Prevention of Cardiovascular Disease, Medical Center Boulevard, Winston Salem, NC, United States of America
| | - Salim S Virani
- Section of Cardiology and Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX 77030, United States of America; Office of the Vice Provost (Research), The Aga Khan University, Karachi 74800, Pakistan
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Kronenberg F, Mora S, Stroes ESG, Ference BA, Arsenault BJ, Berglund L, Dweck MR, Koschinsky ML, Lambert G, Mach F, McNeal CJ, Moriarty PM, Natarajan P, Nordestgaard BG, Parhofer KG, Virani SS, von Eckardstein A, Watts GF, Stock JK, Ray KK, Tokgözoğlu LS, Catapano AL. Frequent questions and responses on the 2022 lipoprotein(a) consensus statement of the European Atherosclerosis Society. Atherosclerosis 2023; 374:107-120. [PMID: 37188555 DOI: 10.1016/j.atherosclerosis.2023.04.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 04/25/2023] [Indexed: 05/17/2023]
Abstract
In 2022, the European Atherosclerosis Society (EAS) published a new consensus statement on lipoprotein(a) [Lp(a)], summarizing current knowledge about its causal association with atherosclerotic cardiovascular disease (ASCVD) and aortic stenosis. One of the novelties of this statement is a new risk calculator showing how Lp(a) influences lifetime risk for ASCVD and that global risk may be underestimated substantially in individuals with high or very high Lp(a) concentration. The statement also provides practical advice on how knowledge about Lp(a) concentration can be used to modulate risk factor management, given that specific and highly effective mRNA-targeted Lp(a)-lowering therapies are still in clinical development. This advice counters the attitude: "Why should I measure Lp(a) if I can't lower it?". Subsequent to publication, questions have arisen relating to how the recommendations of this statement impact everyday clinical practice and ASCVD management. This review addresses 30 of the most frequently asked questions about Lp(a) epidemiology, its contribution to cardiovascular risk, Lp(a) measurement, risk factor management and existing therapeutic options.
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Affiliation(s)
- Florian Kronenberg
- Institute of Genetic Epidemiology, Medical University of Innsbruck, Innsbruck, Austria.
| | - Samia Mora
- Center for Lipid Metabolomics, Division of Preventive Medicine, and Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Erik S G Stroes
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Brian A Ference
- Centre for Naturally Randomized Trials, University of Cambridge, Cambridge, UK
| | - Benoit J Arsenault
- Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, and Department of Medicine, Faculty of Medicine, Université Laval, Québec City, QC, Canada
| | - Lars Berglund
- Department of Internal Medicine, School of Medicine, University of California-Davis, Davis, CA, USA
| | - Marc R Dweck
- British Heart Foundation Centre for Cardiovascular Science, Edinburgh Heart Centre, University of Edinburgh, Chancellors Building, Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Marlys L Koschinsky
- Robarts Research Institute, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Gilles Lambert
- Inserm, UMR 1188 Diabète Athérothrombose Thérapies Réunion Océan Indien (DéTROI), Université de La Réunion, 97400, Saint-Pierre, La Réunion, France
| | - François Mach
- Department of Cardiology, Geneva University Hospital, Geneva, Switzerland
| | - Catherine J McNeal
- Division of Cardiology, Department of Internal Medicine Baylor Scott & White Health, 2301 S. 31st St., Temple, TX, 76508, USA
| | - Patrick M Moriarty
- Atherosclerosis and Lipoprotein-apheresis Clinic, University of Kansas Medical Center, Kansas City, KS, USA
| | - Pradeep Natarajan
- Cardiovascular Research Center and Center for Genomic Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; and Program in Medical and Population Genetics and Cardiovascular Disease Initiative, Broad Institute of Harvard and MIT, Cambridge, MA, USA
| | - Børge G Nordestgaard
- Department of Clinical Biochemistry and the Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev and Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Klaus G Parhofer
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians University Klinikum, Munich, Germany
| | - Salim S Virani
- The Aga Khan University, Karachi, Pakistan; Texas Heart Institute, Baylor College of Medicine, Houston, TX, USA
| | - Arnold von Eckardstein
- Institute of Clinical Chemistry, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Gerald F Watts
- Medical School, University of Western Australia, and Department of Cardiology, Lipid Disorders Clinic, Royal Perth Hospital, Perth, Australia
| | - Jane K Stock
- European Atherosclerosis Society, Mässans Gata 10, SE-412 51, Gothenburg, Sweden
| | - Kausik K Ray
- Imperial Centre for Cardiovascular Disease Prevention, Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Lale S Tokgözoğlu
- Department of Cardiology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Alberico L Catapano
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, and IRCCS MultiMedica, Milan, Italy
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7
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Torres M, Schenk A. Lipoprotein (a): Does It Play a Role in Pediatric Ischemic Stroke and Thrombosis? Curr Atheroscler Rep 2023:10.1007/s11883-023-01102-5. [PMID: 37160656 DOI: 10.1007/s11883-023-01102-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/12/2023] [Indexed: 05/11/2023]
Abstract
PURPOSE OF REVIEW The goal of this paper is to describe the current understanding of lipoprotein (a) (Lp(a)), clinical practice guidelines, and the potential pathophysiological mechanisms that appear to increase the risk of cardiovascular and thromboembolic events, specifically within the pediatric population. RECENT FINDINGS The proatherogenic and pro-thrombotic properties of Lp(a) may increase the risk of atherothrombotic disease. In adults, atherosclerotic plaques increase thrombotic risk, but antifibrinolytic and proinflammatory properties appear to have an important role in children. Although it is not well established in neonates, recent studies indicate the risk of incident thrombosis and ischemic stroke are approximately fourfold higher in children with elevated Lp(a) which also increases their risk of recurrent events. Despite this higher risk, Pediatric Lp(a) screening guidelines continue to vary among different medical societies and countries. The inconsistency is likely related to inconclusive evidence outside of observational studies and the lack of specific therapies for children with elevated levels. Additional research is needed to improve understanding of the pro-thrombotic mechanisms of Lp(a), appropriate screening guidelines for Lp(a) in the pediatric population, and to elucidate the short and long term effects of elevated Lp(a) on the risk of pediatric thrombosis and stroke.
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Affiliation(s)
- Marcela Torres
- Department of Hematology and Oncology, Cook Children's Medical Center, 1500 Cooper St, Fort Worth, TX, 76104, USA.
| | - Allyson Schenk
- Department of Research Data Science and Analytics, Cook Children's Medical Center, 801 Seventh Avenue, Fort Worth, TX, 76104, USA
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Močnik M, Marčun Varda N. Lipid Biomarkers and Atherosclerosis-Old and New in Cardiovascular Risk in Childhood. Int J Mol Sci 2023; 24:ijms24032237. [PMID: 36768558 PMCID: PMC9916711 DOI: 10.3390/ijms24032237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 01/16/2023] [Accepted: 01/20/2023] [Indexed: 01/24/2023] Open
Abstract
Lipids are a complex group of molecules in the body, essential as structural, functional and metabolic components. When disbalanced, they are regarded as a cardiovascular risk factor, traditionally in cholesterol level evaluation. However, due to their complex nature, much research is still needed for a comprehensive understanding of their role in atherosclerosis, especially in the young. Several new lipid biomarkers are emerging, some already researched to a point, such as lipoproteins and apolipoproteins. Other lipid molecules are also being increasingly researched, including oxidized forms due to oxidative inflammation in atherosclerosis, and sphingolipids. For many, even those less new, the atherogenic potential is not clear and no clinical recommendations are in place to aid the clinician in using them in everyday clinical practice. Moreover, lipids' involvement in atherogenesis in children has yet to be elucidated. This review summarizes the current knowledge on lipids as biomarkers of cardiovascular risk in the paediatric population.
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Affiliation(s)
- Mirjam Močnik
- Department of Paediatrics, University Medical Centre Maribor, Ljubljanska Cesta 2, 2000 Maribor, Slovenia
- Correspondence:
| | - Nataša Marčun Varda
- Department of Paediatrics, University Medical Centre Maribor, Ljubljanska Cesta 2, 2000 Maribor, Slovenia
- Faculty of Medicine, University of Maribor, Taborska 8, 2000 Maribor, Slovenia
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Raitakari O, Kartiosuo N, Pahkala K, Hutri-Kähönen N, Bazzano LA, Chen W, Urbina EM, Jacobs DR, Sinaiko A, Steinberger J, Burns T, Daniels SR, Venn A, Woo JG, Dwyer T, Juonala M, Viikari J. Lipoprotein(a) in Youth and Prediction of Major Cardiovascular Outcomes in Adulthood. Circulation 2023; 147:23-31. [PMID: 36440577 PMCID: PMC9797445 DOI: 10.1161/circulationaha.122.060667] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 10/17/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Elevated lipoprotein(a) [Lp(a)] is a common risk factor for cardiovascular disease outcomes with unknown mechanisms. We examined its potential role in identifying youths who are at increased risk of developing adult atherosclerotic cardiovascular disease (ASCVD). METHODS Lp(a) levels measured in youth 9 to 24 years of age were linked to adult ASCVD and carotid intima-media thickness in the YFS (Cardiovascular Risk in Young Finns Study), in which 95 of the original 3596 participants (2.7%) recruited as children have been diagnosed with ASCVD at a median of 47 years of age. Results observed in YFS were replicated with the use of data for White participants from the BHS (Bogalusa Heart Study). In BHS, 587 White individuals had data on youth Lp(a) (measured at 8-17 years of age) and information on adult events, including 15 cases and 572 noncases. Analyses were performed with the use of Cox proportional hazard regression. RESULTS In YFS, those who had been exposed to high Lp(a) level in youth [defined as Lp(a) ≥30 mg/dL] had ≈2 times greater risk of developing adult ASCVD compared with nonexposed individuals (hazard ratio, 2.0 [95% CI, 1.4-2.6]). Youth risk factors, including Lp(a), low-density lipoprotein cholesterol, body mass index, and smoking, were all independently associated with higher risk. In BHS, in an age- and sex-adjusted model, White individuals who had been exposed to high Lp(a) had 2.5 times greater risk (95% CI, 0.9-6.8) of developing adult ASCVD compared with nonexposed individuals. When also adjusted for low-density lipoprotein cholesterol and body mass index, the risk associated with high Lp(a) remained unchanged (hazard ratio, 2.4 [95% CI, 0.8-7.3]). In a multivariable model for pooled data, individuals exposed to high Lp(a) had 2.0 times greater risk (95% CI, 1.0-3.7) of developing adult ASCVD compared with nonexposed individuals. No association was detected between youth Lp(a) and adult carotid artery thickness in either cohort or pooled data. CONCLUSIONS Elevated Lp(a) level identified in youth is a risk factor for adult atherosclerotic cardiovascular outcomes but not for increased carotid intima-media thickness.
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Affiliation(s)
- Olli Raitakari
- Centre for Population Health Research, University of Turku and Turku University Hospital, Finland (O.R., N.K., K.P.)
- Research Centre of Applied and Preventive Cardiovascular Medicine (O.R., N.K., K.P.), University of Turku, Finland
- Department of Clinical Physiology and Nuclear Medicine (O.R.), Turku University Hospital, Finland
| | - Noora Kartiosuo
- Centre for Population Health Research, University of Turku and Turku University Hospital, Finland (O.R., N.K., K.P.)
- Research Centre of Applied and Preventive Cardiovascular Medicine (O.R., N.K., K.P.), University of Turku, Finland
| | - Katja Pahkala
- Centre for Population Health Research, University of Turku and Turku University Hospital, Finland (O.R., N.K., K.P.)
- Research Centre of Applied and Preventive Cardiovascular Medicine (O.R., N.K., K.P.), University of Turku, Finland
- Paavo Nurmi Centre and Unit for Health and Physical Activity (K.P.), University of Turku, Finland
| | - Nina Hutri-Kähönen
- Tampere Centre for Skills Training and Simulation, Tampere University, Finland (N.H.-K.)
| | - Lydia A Bazzano
- Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA (L.A.B., W.C.)
| | - Wei Chen
- Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA (L.A.B., W.C.)
| | - Elaine M Urbina
- Department of Pediatrics, University of Cincinnati College of Medicine, OH (E.M.U., J.G.W.)
- The Heart Institute (E.M.U.), Cincinnati Children's Hospital Medical Center, OH
| | - David R Jacobs
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis (D.R.J.)
| | - Alan Sinaiko
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis (A.S., J.S.)
| | - Julia Steinberger
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis (A.S., J.S.)
| | - Trudy Burns
- Department of Medicine (M.J., J.V.), University of Turku, Finland
| | - Stephen R Daniels
- Department of Pediatrics, University of Colorado School of Medicine, Aurora (S.R.D.)
- Children's Hospital Colorado, Anschutz Medical Campus, Aurora (S.R.D.)
| | - Alison Venn
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia (A.V., T.D.)
| | - Jessica G Woo
- Department of Pediatrics, University of Cincinnati College of Medicine, OH (E.M.U., J.G.W.)
- Division of Biostatistics and Epidemiology (J.G.W.), Cincinnati Children's Hospital Medical Center, OH
| | - Terry Dwyer
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia (A.V., T.D.)
- Heart Research Group, Murdoch Children's Research Institute, Melbourne, Australia (T.D.)
- Nuffield Department of Women's & Reproductive Health, University of Oxford, United Kingdom (T.D.)
| | - Markus Juonala
- Department of Medicine (M.J., J.V.), University of Turku, Finland
- Division of Medicine (M.J., J.V.), Turku University Hospital, Finland
| | - Jorma Viikari
- Department of Medicine (M.J., J.V.), University of Turku, Finland
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10
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Di Fusco SA, Arca M, Scicchitano P, Alonzo A, Perone F, Gulizia MM, Gabrielli D, Oliva F, Imperoli G, Colivicchi F. Lipoprotein(a): a risk factor for atherosclerosis and an emerging therapeutic target. Heart 2022; 109:18-25. [PMID: 35288443 DOI: 10.1136/heartjnl-2021-320708] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 02/16/2022] [Indexed: 02/04/2023] Open
Abstract
Lipoprotein(a) (Lp(a)) is a complex circulating lipoprotein, and increasing evidence has demonstrated its role as a risk factor for atherosclerotic cardiovascular disease (ASCVD) and as a possible therapeutic target. Lp(a) atherogenic effects are attributed to several potential mechanisms in addition to cholesterol accumulation in the arterial wall, including proinflammatory effects mainly mediated by oxidised phospholipids. Several studies have found a causal and independent relationship between Lp(a) levels and cardiovascular risk. Furthermore, several studies also suggest a causal association between Lp(a) levels and calcific aortic valve stenosis. Available lipid-lowering agents have at best moderate impact on Lp(a) levels. Among available therapies, antibody proprotein convertase subtilisin/kexin type 9 inhibitors are the most effective in reducing Lp(a). Potent Lp(a)-lowering treatments that target LPA expression are under development. Lp(a) level measurement poses some challenges due to the absence of a definitive reference method and the reporting of Lp(a) values as molar (nanomoles per litre (nmol/L)) or mass concentrations (milligrams per decilitre (mg/dL)) by different assays. Currently, Lp(a) measurement is recommended to refine cardiovascular risk in specific clinical settings, that is, in individuals with a family history of premature ASCVD, in patients with ASCVD not explained by standard risk factors or in those with recurrent events despite optimal management of traditional risk factors. Patients with high Lp(a) levels should be managed with more intensive approaches to treat other modifiable cardiovascular risk factors. Overall, this review focuses on Lp(a) as an ASCVD risk factor and therapeutic target. Furthermore, it reports practical recommendations for Lp(a) measurement and interpretation and updated evidence on Lp(a)-lowering approaches.
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Affiliation(s)
| | - Marcello Arca
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | | | | | | | - Michele Massimo Gulizia
- Cardiology Division, Garibaldi-Nesima Hospital, Garibaldi-Nesima Hospital, Catania, Italy.,Heart Care Foundation, Florence, Italy
| | | | - Fabrizio Oliva
- De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy
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11
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Abstract
PURPOSE OF THE REVIEW Over the past decade, lipoprotein(a) [Lp(a)] made it to several consensus and guideline documents. This review aims to summarize the literature which underlies the various recommendations and compares recent European and North American consensus and guideline documents of the recent 3-4 years. RECENT FINDINGS Multiple large epidemiological and genetic studies have provided strong evidence for a causal association between Lp(a) concentrations and atherosclerotic cardiovascular disease (ASCVD) and aortic valve stenosis. There is a dose-dependent linear relationship between Lp(a) and ASCVD risk advocating to consider Lp(a) on a continuous scale rather than using thresholds. The best way to implement this in the clinic is by individualizing the Lp(a)-related risk using tools such as the 'Lp(a) risk calculator' ( http://www.lpaclinicalguidance.com ) that takes into account the Lp(a) level in the context of an individual's traditional risk factors and global risk for ASCVD. There is growing agreement across the guidelines regarding the clinical utility of measuring Lp(a) and more recent expert groups advocate for a general screening approach applied to all adults. As long as the cardiovascular outcomes trials for specific Lp(a)-lowering drugs are in progress, the current management of patients with high Lp(a) should focus on the comprehensive management of all other modifiable ASCVD risk factors which can be therapeutically addressed as per guideline recommendations. SUMMARY Since the contribution of high Lp(a) concentrations to global ASCVD risk has been underestimated in the past, a clear recommendation to measure Lp(a) at least once in a person's lifetime is imperative. Recent expert consensus recommendations provide clinicians with direction on how to manage the excess risk associated with elevated Lp(a) concentration by comprehensive and individualized management of modifiable ASCVD risk factors while awaiting the results of clinical trials of Lp(a) targeted therapies.
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Affiliation(s)
- Florian Kronenberg
- Institute of Genetic Epidemiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Samia Mora
- Center for Lipid Metabolomics, Division of Preventive Medicine, and Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Erik S.G. Stroes
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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12
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Schefelker JM, Peterson AL. Screening and Management of Dyslipidemia in Children and Adolescents. J Clin Med 2022; 11:6479. [PMID: 36362707 PMCID: PMC9656613 DOI: 10.3390/jcm11216479] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 10/24/2022] [Accepted: 10/29/2022] [Indexed: 07/30/2023] Open
Abstract
This review provides an overview of pediatric dyslipidemia emphasizing screening and treatment recommendations. The presence of risk factors for cardiovascular disease in childhood poses significant risk for the development of atherosclerotic cardiovascular disease and cardiovascular events in adulthood. While atherogenic dyslipidemia is the most common dyslipidemia seen in children and can be suspected based on the presence of risk factors (such as obesity), familial hypercholesterolemia can be found in children with no risk factors. As such, universal cholesterol screening is recommended to identify children with these disorders in order to initiate treatment and reduce the risk of future cardiovascular disease. Treatment of pediatric dyslipidemia begins with lifestyle modifications, but primary genetic dyslipidemias may require medications such as statins. As pediatric lipid disorders often have genetic or familial components, it is important that all physicians are aware that cardiovascular risk begins in childhood, and can both identify these disorders in pediatric patients and counsel their adult patients with dyslipidemia to have their children screened.
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Affiliation(s)
| | - Amy L. Peterson
- Department of Pediatrics, Division of Pediatric Cardiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI 53792, USA
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13
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Kronenberg F, Mora S, Stroes ESG, Ference BA, Arsenault BJ, Berglund L, Dweck MR, Koschinsky M, Lambert G, Mach F, McNeal CJ, Moriarty PM, Natarajan P, Nordestgaard BG, Parhofer KG, Virani SS, von Eckardstein A, Watts GF, Stock JK, Ray KK, Tokgözoğlu LS, Catapano AL. Lipoprotein(a) in atherosclerotic cardiovascular disease and aortic stenosis: a European Atherosclerosis Society consensus statement. Eur Heart J 2022; 43:3925-3946. [PMID: 36036785 PMCID: PMC9639807 DOI: 10.1093/eurheartj/ehac361] [Citation(s) in RCA: 238] [Impact Index Per Article: 119.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 05/10/2022] [Accepted: 06/21/2022] [Indexed: 12/20/2022] Open
Abstract
This 2022 European Atherosclerosis Society lipoprotein(a) [Lp(a)] consensus statement updates evidence for the role of Lp(a) in atherosclerotic cardiovascular disease (ASCVD) and aortic valve stenosis, provides clinical guidance for testing and treating elevated Lp(a) levels, and considers its inclusion in global risk estimation. Epidemiologic and genetic studies involving hundreds of thousands of individuals strongly support a causal and continuous association between Lp(a) concentration and cardiovascular outcomes in different ethnicities; elevated Lp(a) is a risk factor even at very low levels of low-density lipoprotein cholesterol. High Lp(a) is associated with both microcalcification and macrocalcification of the aortic valve. Current findings do not support Lp(a) as a risk factor for venous thrombotic events and impaired fibrinolysis. Very low Lp(a) levels may associate with increased risk of diabetes mellitus meriting further study. Lp(a) has pro-inflammatory and pro-atherosclerotic properties, which may partly relate to the oxidized phospholipids carried by Lp(a). This panel recommends testing Lp(a) concentration at least once in adults; cascade testing has potential value in familial hypercholesterolaemia, or with family or personal history of (very) high Lp(a) or premature ASCVD. Without specific Lp(a)-lowering therapies, early intensive risk factor management is recommended, targeted according to global cardiovascular risk and Lp(a) level. Lipoprotein apheresis is an option for very high Lp(a) with progressive cardiovascular disease despite optimal management of risk factors. In conclusion, this statement reinforces evidence for Lp(a) as a causal risk factor for cardiovascular outcomes. Trials of specific Lp(a)-lowering treatments are critical to confirm clinical benefit for cardiovascular disease and aortic valve stenosis.
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Affiliation(s)
- Florian Kronenberg
- Institute of Genetic Epidemiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Samia Mora
- Center for Lipid Metabolomics, Division of Preventive Medicine, and Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Erik S G Stroes
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Brian A Ference
- Centre for Naturally Randomized Trials, University of Cambridge, Cambridge, UK
| | - Benoit J Arsenault
- Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, and Department of Medicine, Faculty of Medicine, Université Laval, Québec City, QC, Canada
| | - Lars Berglund
- Department of Internal Medicine, School of Medicine, University of California-Davis, Davis, Sacramento, CA, USA
| | - Marc R Dweck
- British Heart Foundation Centre for Cardiovascular Science, Edinburgh Heart Centre, University of Edinburgh, Chancellors Building, Little France Crescent, Edinburgh EH16 4SB, UK
| | - Marlys Koschinsky
- Robarts Research Institute, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Gilles Lambert
- Inserm, UMR 1188 Diabète Athérothrombose Thérapies Réunion Océan Indien (DéTROI), Université de La Réunion, 97400 Saint-Denis de La Reunion, France
| | - François Mach
- Department of Cardiology, Geneva University Hospital, Geneva, Switzerland
| | - Catherine J McNeal
- Division of Cardiology, Department of Internal Medicine, Baylor Scott & White Health, 2301 S. 31st St., USA
| | | | - Pradeep Natarajan
- Cardiovascular Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, and Program in Medical and Population Genetics and Cardiovascular Disease Initiative, Broad Institute of Harvard and MIT, Cambridge, MA, USA
| | - Børge G Nordestgaard
- Department of Clinical Biochemistry and the Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Klaus G Parhofer
- Medizinische Klinik und Poliklinik IV, Ludwigs- Maximilians University Klinikum, Munich, Germany
| | - Salim S Virani
- Section of Cardiovascular Research, Baylor College of Medicine & Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Arnold von Eckardstein
- Institute of Clinical Chemistry, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Gerald F Watts
- Medical School, University of Western Australia, and Department of Cardiology, Lipid Disorders Clinic, Royal Perth Hospital, Perth, Australia
| | - Jane K Stock
- European Atherosclerosis Society, Mässans Gata 10, SE-412 51 Gothenburg, Sweden
| | - Kausik K Ray
- Imperial Centre for Cardiovascular Disease Prevention, Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Lale S Tokgözoğlu
- Department of Cardiology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Alberico L Catapano
- Department of Pharmacological and Biomolecular Sciences, University of Milano, Milano, Italy.,IRCCS Multimedica, Milano, Italy
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14
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Wilson DP, Jacobson TA, Jones PH, Koschinsky ML, McNeal CJ, Nordestgaard BG, Orringer CE. Use of Lipoprotein(a) in clinical practice: A biomarker whose time has come. A scientific statement from the National Lipid Association. J Clin Lipidol 2022; 16:e77-e95. [PMID: 36068139 DOI: 10.1016/j.jacl.2022.08.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Lipoprotein(a) [Lp(a)] is a well-recognized, independent risk factor for atherosclerotic cardiovascular disease, with elevated levels estimated to be prevalent in 20% of the population. Observational and genetic evidence strongly support a causal relationship between high plasma concentrations of Lp(a) and increased risk of atherosclerotic cardiovascular disease-related events, such as myocardial infarction and stroke, and valvular aortic stenosis. In this scientific statement, we review an array of evidence-based considerations for testing of Lp(a) in clinical practice and the utilization of Lp(a) levels to inform treatment strategies in primary and secondary prevention.
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Affiliation(s)
- Don P Wilson
- Department of Pediatric Endocrinology and Diabetes, Cook Children''s Medical Center, Fort Worth, TX, USA.
| | - Terry A Jacobson
- Department of Medicine, Lipid Clinic and Cardiovascular Risk Reduction Program, Emory University, Atlanta, GA, USA
| | - Peter H Jones
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Marlys L Koschinsky
- Robarts Research Institute, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, Ontario, Canada
| | - Catherine J McNeal
- Division of Cardiology, Department of Internal Medicine, Baylor Scott & White Health, Temple, TX, USA
| | - Børge G Nordestgaard
- Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
| | - Carl E Orringer
- Division of Cardiology, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
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15
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Plasma lipoprotein (a) and tissue plasminogen activator are associated with increased risk of atherosclerotic cardiovascular disease. Heliyon 2022; 8:e09836. [PMID: 35815138 PMCID: PMC9260301 DOI: 10.1016/j.heliyon.2022.e09836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 04/09/2022] [Accepted: 06/27/2022] [Indexed: 12/01/2022] Open
Abstract
Atherosclerotic cardiovascular disease (ASCVD) is the most common cause of mortality. Lipoprotein a (Lp(a)) is a low-density lipoprotein (LDL)-like particle with a similar structure to tissue plasminogen activator (t-PA) and it competes with plasminogen for its binding site leading to reduced fibrinolysis. The aim of this study was to assess association of Lp(a) and t-PA levels with risk of ASCVD and whether they are dependent on LDL levels. Patients who presented to the catheterization lab for assessment of coronary artery disease were included and stratified by their risk of ASCVD into low, moderate, high, and very high risk. Plasma levels of Lp(a) and t-PA levels were measured before catheterization. Consecutive patients (n = 362) were included. The mean age±sem was 52.28 ± 0.60 years. Plasma Lp(a) and t-PA levels were higher in very-high and high-risk patients relative to low-risk patients. Serum levels of triglyceride and high-density lipoprotein but not LDL were correlated with risk of ASCVD. Plasma Lp(a) and t-PA were not correlated or modified with LDL level. Plasma Lp(a) and t-PA levels were higher in patients undergoing coronary revascularization relative to patients having no intervention. Plasma t-PA level was higher in patients presented with myocardial infarction compared to those with angina. Multivariate analysis documented independent association of Lp(a) and t-PA with ASCVD risk. Plasma Lp(a) and t-PA levels are associated with increased ASCVDASCVD risk independent of LDL and could be used as predictors of atherosclerosis risk and in selecting patients who may benefit from coronary revascularization.
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16
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Dandapat S, Guerrero WR, Ortega-Gutierrez S. Acute StrokeTreatment in Children: Are Adult Guidelines Applicable? Curr Treat Options Neurol 2022; 24:41-54. [PMID: 35509674 PMCID: PMC9060549 DOI: 10.1007/s11940-022-00707-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Purpose of this Review This article provides an overview into acute treatments in stroke which are widely studied and available for adults and their applicability in the pediatric population. Recent Findings Arterial ischemic stroke is an important cause of morbidity and mortality in the pediatric population. Neurological deficits and etiologies are age-dependent and more challenging to diagnose than in the adult population. Advancements in imaging and treatment modalities including increased treatment windows in acute stroke have led to improvement in the diagnosis and management of pediatric arterial ischemic disease. Accordingly, hyperacute treatments, such as endovascular therapy, are becoming increasingly available in an attempt to improve outcomes in children. Summary Significant scientific and technological advances have transformed the hyperacute treatment of stroke in the recent years, allowing for improvement in the diagnosis and treatment of cerebrovascular pathologies in children. Optimization in the approach, and validation of existing stroke pathways/protocols is expected to further advance acute stroke therapy in pediatric patient care. Given that the lifelong individual, family, and societal burden of acute stroke is likely to be greater than in adults because infants and children surviving stroke live more years with disability, we must be knowledgeable about this pathology and the medical and therapeutic options available for this unique population as detailed in this review.
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Affiliation(s)
- Sudeepta Dandapat
- Department of Neurosciences, Aurora Neuroscience Innovation Institute, St.Luke’s Hospital, Milwaukee, WI
| | - Waldo R. Guerrero
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL
| | - Santiago Ortega-Gutierrez
- Department of Neurology, Radiology and Neurosurgery, University of Iowa Comprehensive Stroke Center, Iowa City, IA
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17
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Oraby MI, Soliman RH, Abd Elkareem RM, Mohammed AI. Copeptin: a potential blood biomarker for acute ischemic stroke. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2021. [DOI: 10.1186/s41983-021-00393-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Copeptin is a new blood biomarker for acute ischemic stroke which emerged to assist clinicians with decision-making. Serum copeptin can accurately reflect vasopressin concentration, which plays a role in aggravation of inflammatory responses, ions and neurotransmitters dysfunctions. The objective of this work was to investigate the relation between copeptin level as a blood biomarker and the short-term prognosis of acute ischemic stroke after 3 months. The current study included 45 patients with first ever acute ischemic stroke and 45 healthy volunteers as a control. Clinical evaluation, CT and MRI of the brain, NIHSS on admission, and mRS after 3 months were done for the patients, and all the patients and control were subjected to assessment of serum level of copeptin by ELISA technique.
Results
Copeptin level was significantly higher in patients with acute ischemic stroke compared to healthy control subjects (p-value = 0.001). Also, copeptin level was significantly higher in patients with severe stroke (NIHSS > 16) than in those with mild-to-moderate stroke (NIHSS 0–15) at presentation and in patients with unfavorable outcome (mRS 3–6) when compared to patients with favorable outcome (mRS 0–2) (p-value = 0.003 and 0.001, respectively).
Copeptin level was significantly lower in patients who received thrombolytic therapy with rTPA (p-value = 0.049).
Conclusion
Copeptin has an interesting potential as a new prognostic biomarker for patients with acute ischemic stroke as its level was significantly higher in patients with severe stroke and in patients with unfavorable outcome.
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18
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Rodríguez-Moran M, Gamboa-Gómez CI, Preza-Rodríguez L, Guerrero-Romero F. Lipoprotein(a) and Hyperinsulinemia in Healthy Normal-weight, Prepubertal Mexican Children. Endocr Res 2021; 46:87-91. [PMID: 33554676 DOI: 10.1080/07435800.2021.1881966] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Background. Given the numerous gaps in our knowledge about the biological interactions of lipoprotein(a) [Lp(a)], we determined whether Lp(a) was associated with hyperinsulinemia in healthy normal-weight, prepubertal children.Methods. A total of 131 healthy normal-weight Mexican children aged 6 to 9 years at Tanner stage 1 who were born appropriate for gestational age were enrolled in a case-control study. Children with hyperinsulinemia were allocated into the case group (n = 32), and children with normal insulin levels were allocated into the control group (n = 99). Birth weight, age, and body mass index were matching criteria. Multivariate logistic regression analysis was used to compute the odds ratio (OR) between Lp(a) and both hyperinsulinemia and insulin resistance. Furthermore, a multivariate linear regression analysis was performed to evaluate the association between Lp(a) and both insulin levels and HOMA-IR. Both models were adjusted by sex, age, birth weight, and body mass index.Results. The median (25-75 percentile) serum levels of Lp(a) [20.0 (13.7-29.6) versus 14.6 (10.6-26.7) mg/dL, p = .003] and insulin [24.5 (6.0-30) versus 7.9 (4.3-9.0) µU/L, p < .0005] were higher in the case group than in the control group. The logistic regression analysis showed that Lp(a) was associated with hyperinsulinemia (OR 5.86; 95%CI 2.5-13.6, p < .0005) and insulin resistance (OR 2.01; 95%CI 1.1-9.9, p = .004). In addition, the linear regression analysis showed a significant association between serum Lp(a) and insulin levels (β 11.1; 95%CI 1.8-10.9, p < .0001) and the HOMA-IR index (β 2.606; 95%CI 2.3-2.9, p < .0005).Conclusion. Lp(a) was associated with hyperinsulinemia and insulin resistance in healthy normal-weight, prepubertal children.
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Affiliation(s)
| | | | - Lucia Preza-Rodríguez
- Biomedical Research Unit, Mexican Social Security Institute. Durango, Dgo., Mexico
- Facultad De Medicina Y Nutrición, Universidad Juárez Del Estado, Durango, Dgo, México
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19
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The Association of Lipoprotein(a) and Circulating Monocyte Subsets with Severe Coronary Atherosclerosis. J Cardiovasc Dev Dis 2021; 8:jcdd8060063. [PMID: 34206012 PMCID: PMC8228191 DOI: 10.3390/jcdd8060063] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 05/21/2021] [Accepted: 05/25/2021] [Indexed: 01/02/2023] Open
Abstract
Background and aims: Chronic inflammation associated with the uncontrolled activation of innate and acquired immunity plays a fundamental role in all stages of atherogenesis. Monocytes are a heterogeneous population and each subset contributes differently to the inflammatory process. A high level of lipoprotein(a) (Lp(a)) is a proven cardiovascular risk factor. The aim of the study was to investigate the association between the increased concentration of Lp(a) and monocyte subpopulations in patients with a different severity of coronary atherosclerosis. Methods: 150 patients (124 males) with a median age of 60 years undergoing a coronary angiography were enrolled. Lipids, Lp(a), autoantibodies, blood cell counts and monocyte subpopulations (classical, intermediate, non-classical) were analyzed. Results: The patients were divided into two groups depending on the Lp(a) concentration: normal Lp(a) < 30 mg/dL (n = 82) and hyperLp(a) ≥ 30 mg/dL (n = 68). Patients of both groups were comparable by risk factors, autoantibody levels and blood cell counts. In patients with hyperlipoproteinemia(a) the content (absolute and relative) of non-classical monocytes was higher (71.0 (56.6; 105.7) vs. 62.2 (45.7; 82.4) 103/mL and 17.7 (13.0; 23.3) vs. 15.1 (11.4; 19.4) %, respectively, p < 0.05). The association of the relative content of non-classical monocytes with the Lp(a) concentration retained a statistical significance when adjusted for gender and age (r = 0.18, p = 0.03). The severity of coronary atherosclerosis was associated with the Lp(a) concentration as well as the relative and absolute (p < 0.05) content of classical monocytes. The high content of non-classical monocytes (OR = 3.5, 95% CI 1.2–10.8) as well as intermediate monocytes (OR = 8.7, 2.5–30.6) in patients with hyperlipoproteinemia(a) were associated with triple-vessel coronary disease compared with patients with a normal Lp(a) level and a low content of monocytes. Conclusion: Hyperlipoproteinemia(a) and a decreased quantity of classical monocytes were associated with the severity of coronary atherosclerosis. The expansion of CD16+ monocytes (intermediate and non-classical) in the presence of hyperlipoproteinemia(a) significantly increased the risk of triple-vessel coronary disease.
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Wilson DP, Koschinsky ML, Moriarty PM. Expert position statements: comparison of recommendations for the care of adults and youth with elevated lipoprotein(a). Curr Opin Endocrinol Diabetes Obes 2021; 28:159-173. [PMID: 33534258 DOI: 10.1097/med.0000000000000624] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Summarize recent recommendations on clinical management of adults and youth with elevated lipoprotein(a) [Lp(a)] who are at-risk of or affected by cardiovascular disease (CVD). RECENT FINDINGS There is ample evidence to support elevated Lp(a) levels, present in approximately 20% of the general population, as a causal, independent risk factor for CVD and its role as a significant risk enhancer. Several guidelines and position statements have been published to assist in the identification, treatment and follow-up of adults with elevated levels of Lp(a). There is growing interest in Lp(a) screening and strategies to improve health behaviors starting in youth, although published recommendations for this population are limited. In addition to the well established increased risk of myocardial infarction, stroke and valvular aortic stenosis, data from the coronavirus pandemic suggest adults with elevated Lp(a) may have a particularly high-risk of cardiovascular complications. Lp(a)-specific-lowering therapies are currently in development. Despite their inability to lower Lp(a), use of statins have been shown to improve outcomes in primary and secondary prevention. SUMMARY Considerable differences exist amongst published guidelines for adults on the use of Lp(a) in clinical practice, and recommendations for youth are limited. With increasing knowledge of Lp(a)'s role in CVD, including recent observations of COVID-19-related risk of cardiovascular complications, more harmonized and comprehensive guidelines for Lp(a) in clinical practice are required. This will facilitate clinical decision-making and help define best practices for identification and management of elevated Lp(a) in adults and youth.
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Affiliation(s)
- Don P Wilson
- Department of Pediatric Endocrinology, Fort Worth, Texas, USA
| | - Marlys L Koschinsky
- Robarts Research Institute, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, Ontario, Canada
| | - Patrick M Moriarty
- The Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
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21
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Should Lipoprotein(a) be Measured in Youth? J Pediatr 2021; 228:285-289. [PMID: 32822740 DOI: 10.1016/j.jpeds.2020.08.042] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 08/12/2020] [Accepted: 08/14/2020] [Indexed: 01/06/2023]
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Abstract
PURPOSE OF REVIEW Cardiovascular disease (CVD) can begin in youth. Prevention is essential to reducing the burden of CVD-related risk factors in childhood and disease development in adulthood. This review addresses the clinical scope of CVD prevention, including a review of conditions encountered, proposed diagnostic criteria, and management strategies. We also highlight the impact of the intrauterine environment on the development of CVD risk. Finally, we highlight the potential role of telehealth in the management of pediatric patients with risk factors for premature CVD. RECENT FINDINGS Growing evidence suggests that maternal obesity, diabetes, and preeclampsia may play an important role in the development of CVD risk among offspring contributing to the development of known traditional CVD risk factors among offspring. As the prevalence of CVD continues to rise, knowledge as well as appropriate diagnosis and management of primordial and traditional risk factors for CVD is needed. The diagnosis and management of CVD risk factors is a central role of the preventive pediatric cardiologist, but it is imperative that the general physician and other pediatric subspecialists be aware of these risk factors, diagnoses, and management strategies. Finally, telehealth may offer an additional method for providing preventive care, including screening and counseling of at risk children and adolescents for traditional risk factors and for providing education regarding risk factors in cases of long distance care and/or during periods of social distancing.
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Langsted A, Nordestgaard BG, Kamstrup PR. Elevated Lipoprotein(a) and Risk of Ischemic Stroke. J Am Coll Cardiol 2020; 74:54-66. [PMID: 31272552 DOI: 10.1016/j.jacc.2019.03.524] [Citation(s) in RCA: 109] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 03/21/2019] [Accepted: 03/24/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND High lipoprotein(a) is associated with increased risk of myocardial infarction and aortic valve stenosis. Previous studies have examined the association of lipoprotein(a) and risk of stroke; however, the results are conflicting. OBJECTIVES The purpose of this study was to test if high lipoprotein(a) is associated with high risk of ischemic stroke observationally and causally from human genetics. METHODS The study included 49,699 individuals from the Copenhagen General Population Study and 10,813 individuals from the Copenhagen City Heart Study with measurements of plasma lipoprotein(a), LPA kringle-IV type 2 number of repeats, and LPA rs10455872. The endpoint of ischemic stroke was ascertained from Danish national health registries and validated by medical doctors. RESULTS Compared with individuals with lipoprotein(a) levels <10 mg/dl (<18 nmol/l: first to 50th percentile), the multivariable-adjusted hazard ratio for ischemic stroke was 1.60 (95% confidence interval [CI]:1.24 to 2.05) for individuals with lipoprotein(a) levels >93mg/dl (>199 nmol/L: 96th to 100th percentile). In observational analyses for a 50 mg/dl (105 nmol/l) higher lipoprotein(a) level the age- and sex-adjusted hazard ratio for ischemic stroke was 1.20 (95% CI: 1.13 to 1.28), while the corresponding age- and sex-adjusted genetic causal risk ratio for KIV-2 number of repeats was 1.20 (95% CI: 1.02 to 1.43) and for rs10455872 was 1.27 (95% CI: 1.06 to 1.51). The highest absolute 10-year risk of ischemic stroke was 17% in active smoking individuals >70 years of age with hypertension and lipoprotein(a) levels >93 mg/dl (>199 nmol/l: 96th to 100th percentile). In the Copenhagen City Heart Study, risk estimates for high levels of lipoprotein(a) were in the same direction but did not reach statistical significance. CONCLUSIONS In a large contemporary general population study, high plasma levels of lipoprotein(a) were associated with increased risk of ischemic stroke both observationally and causally from human genetics.
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Affiliation(s)
- Anne Langsted
- Department of Clinical Biochemistry and the Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Copenhagen, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Børge G Nordestgaard
- Department of Clinical Biochemistry and the Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Copenhagen, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Copenhagen City Heart Study, Frederiksberg Hospital, Copenhagen University Hospital, Copenhagen, Denmark
| | - Pia R Kamstrup
- Department of Clinical Biochemistry and the Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Copenhagen, Denmark.
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Fu H, Zhang D, Zhu R, Cui L, Qiu L, Lin S, Peng B. Association between lipoprotein(a) concentration and the risk of stroke in the Chinese Han population: a retrospective case-control study. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:212. [PMID: 32309359 PMCID: PMC7154407 DOI: 10.21037/atm.2020.01.38] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background Lipoprotein(a) [Lp(a)] is a risk factor of coronary heart disease, however, its effects on stroke are less well-defined. Methods We performed a single-center, retrospective case-control study in 1,953 and 196 ischemic stroke and hemorrhagic stroke in-hospital patients, respectively. Controls were healthy individuals that were matched for sex and age (±5 years) for the ischemic (1:1 ratio) and hemorrhagic (1:2 ratio) stroke. Lp(a) concentration was measured using the latex agglutination turbidimetric method. Logarithmic transformation and quartile categorization were applied to adjust for the skewed distribution of Lp(a). Conditional logistic regression models were used to assess the association between Lp(a) and stroke risk. Results Median Lp(a) concentration was higher in stroke patients when compared with controls (12.2 vs. 8.60 mg/dL) and hemorrhagic strokes (14.40 vs. 13.40 mg/dL). The conditional multivariate analysis revealed a positive association between Lp(a) and ischemic stroke (OR =2.03, 2.36, and 2.03 for quartiles 2, 3 and 4, respectively, vs. quartile 1; P<0.001). In addition, elevated Lp(a) was also significantly associated with increased hemorrhagic stroke risk, after adjusted for potential covariates (OR =1.93, 3.24, and 2.19 for quartile 2, 3 and 4 respectively vs. quartile 1, P<0.05). The stratified analyses for ischemic and hemorrhagic stroke revealed significant association between elevated log-transformed Lp(a) and ischemic stroke in men. Furthermore, there was a trend towards a higher stroke risk for younger patients compared with older patients. Conclusions Elevated serum Lp(a) is significantly positively correlated with ischemic and hemorrhagic stroke risk in the Chinese Han population, especially among men and younger patients.
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Affiliation(s)
- Hanhui Fu
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Dingding Zhang
- Central Research Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Rui Zhu
- Department of Medical Record, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Liying Cui
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Ling Qiu
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Songbai Lin
- Department of Health Examination Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Bin Peng
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
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Gerstl L, Weinberger R, Heinen F, Bonfert MV, Borggraefe I, Schroeder AS, Tacke M, Landgraf MN, Vill K, Kurnik K, Sorg AL, Olivieri M. Arterial ischemic stroke in infants, children, and adolescents: results of a Germany-wide surveillance study 2015–2017. J Neurol 2019; 266:2929-2941. [DOI: 10.1007/s00415-019-09508-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 08/01/2019] [Accepted: 08/13/2019] [Indexed: 12/13/2022]
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Use of Lipoprotein(a) in clinical practice: A biomarker whose time has come. A scientific statement from the National Lipid Association. J Clin Lipidol 2019; 13:374-392. [DOI: 10.1016/j.jacl.2019.04.010] [Citation(s) in RCA: 202] [Impact Index Per Article: 40.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 04/26/2019] [Accepted: 04/26/2019] [Indexed: 12/24/2022]
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Julius U, Tselmin S, Schatz U, Fischer S, Bornstein SR. Lipoprotein(a)-an interdisciplinary challenge. Clin Res Cardiol Suppl 2019; 14:20-27. [PMID: 30838556 DOI: 10.1007/s11789-019-00098-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Lipoprotein(a) (Lp(a)) is an internationally recognized atherogenic risk factor which is inherited and not changed by nutrition or physical activity. At present, only proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors may modestly decrease its concentration (but not in all patients)-leading to a certain decrease in cardiovascular events (CVE) in controlled studies. However, at present an elevation of Lp(a) is not a generally accepted indication for their use. More effective is lipoprotein apheresis (LA) therapy with respect to both lowering Lp(a) levels and reduction of CVE. In the future, an antisense oligonucleotide against apolipoprotein(a) will probably be available. Atherosclerosis in patients with an elevation of Lp(a) may affect several vessel regions (carotids, aorta, coronaries, leg arteries). Thus, Lp(a) should be measured in high-risk patients. These patients are usually cared for by their family doctors and by other specialists who should closely cooperate. Lipidologists should decide whether costly therapies like PCSK9 inhibitors or LA should be started. The main aim of current therapy is to optimize all other risk factors (LDL cholesterol, hypertension, diabetes mellitus, body weight, renal insufficiency). Patients should be regularly monitored (lab data, heart, arteries). This paper describes the duties of physicians of different specialties when caring for patients with high Lp(a) concentrations.
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Affiliation(s)
- U Julius
- Lipidology and Center for Extracorporeal Treatment, Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany.
| | - S Tselmin
- Lipidology and Center for Extracorporeal Treatment, Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - U Schatz
- Lipidology and Center for Extracorporeal Treatment, Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - S Fischer
- Lipidology and Center for Extracorporeal Treatment, Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - S R Bornstein
- Lipidology and Center for Extracorporeal Treatment, Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany
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Enas EA, Varkey B, Dharmarajan TS, Pare G, Bahl VK. Lipoprotein(a): An independent, genetic, and causal factor for cardiovascular disease and acute myocardial infarction. Indian Heart J 2019; 71:99-112. [PMID: 31280836 PMCID: PMC6620428 DOI: 10.1016/j.ihj.2019.03.004] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Revised: 02/10/2019] [Accepted: 03/13/2019] [Indexed: 12/24/2022] Open
Abstract
Lipoprotein(a) [Lp(a)] is a circulating lipoprotein, and its level is largely determined by variation in the Lp(a) gene (LPA) locus encoding apo(a). Genetic variation in the LPA gene that increases Lp(a) level also increases coronary artery disease (CAD) risk, suggesting that Lp(a) is a causal factor for CAD risk. Lp(a) is the preferential lipoprotein carrier for oxidized phospholipids (OxPL), a proatherogenic and proinflammatory biomarker. Lp(a) adversely affects endothelial function, inflammation, oxidative stress, fibrinolysis, and plaque stability, leading to accelerated atherothrombosis and premature CAD. The INTER-HEART Study has established the usefulness of Lp(a) in assessing the risk of acute myocardial infarction in ethnically diverse populations with South Asians having the highest risk and population attributable risk. The 2018 Cholesterol Clinical Practice Guideline have recognized elevated Lp(a) as an atherosclerotic cardiovascular disease risk enhancer for initiating or intensifying statin therapy.
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Affiliation(s)
- Enas A Enas
- Coronary Artery Disease in Indians (CADI) Research Foundation, Lisle, IL USA.
| | - Basil Varkey
- Emeritus of Medicine, Medical College of Wisconsin, USA
| | - T S Dharmarajan
- Medicine, Albert Einstein College of Medicine, Bronx, NY, USA; Department of Medicine, Montefiore Medical Center (Wakefield Campus), Bronx, NY, USA
| | | | - Vinay K Bahl
- Department of Cardiology, All India Institute of Medical Sciences New Delhi, India
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Sultan S, Dowling M, Kirton A, DeVeber G, Linds A, Elkind MSV. Dyslipidemia in Children With Arterial Ischemic Stroke: Prevalence and Risk Factors. Pediatr Neurol 2018; 78:46-54. [PMID: 29229232 PMCID: PMC5776751 DOI: 10.1016/j.pediatrneurol.2017.09.019] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 09/27/2017] [Accepted: 09/29/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Risk factors for pediatric stroke are poorly understood and require study to improve prevention. Total cholesterol and triglyceride values peak to near-adult levels before puberty, a period of increased stroke incidence. The role of lipids in childhood arterial ischemic stroke has been minimally investigated. METHODS We performed a cross-sectional analysis of lipid and Lp(a) concentrations in children with arterial ischemic stroke in the International Pediatric Stroke Study to compare the prevalence of dyslipidemia and high- or low-ranking lipid values in our dataset with reported population values. We analyzed sex, body mass index, race, ethnicity, family history, and stroke risk factors for associations with dyslipidemia, high non-high-density lipoprotein cholesterol, and hypertriglyceridemia. RESULTS Compared with the National Health and Nutrition Examination Survey, a higher proportion of children ≥5 years with arterial ischemic stroke had dyslipidemia (38.4% versus 21%), high total cholesterol (10.6% versus 7.4%), high non-high-density lipoprotein cholesterol (23.1% versus 8.4%), and low high-density lipoprotein cholesterol (39.8% versus 13.4%). The lipid values that corresponded to one standard deviation above the mean (84th percentile) in multiple published national studies generally corresponded to a lower ranking percentile in children aged five years or older with arterial ischemic stroke. Dyslipidemia was more likely associated with an underweight, overweight, or obese body mass index compared with a healthy weight. Ethnic background and an acute systemic illness were also associated with abnormal lipids. CONCLUSIONS Dyslipidemia and hypertriglyceridemia may be more prevalent in children with arterial ischemic stroke compared with stroke-free children.
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Affiliation(s)
- Sally Sultan
- Department of Pediatrics, Columbia University Medical Center, New York, New York.
| | - Michael Dowling
- Department of Pediatrics and Neurology & Neurotherapeutics, Division of Pediatric Neurology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Adam Kirton
- Calgary Pediatric Stroke Program, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Gabrielle DeVeber
- Division of Neurology and Labatt Family Heart Centre, Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Alexandra Linds
- Division of Neurology, Child Health Evaluative Sciences Program, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Mitchell S V Elkind
- Department of Neurology, College of Physicians and Surgeons, Columbia University, New York; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York
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Lp(a) in Childhood. CURRENT CARDIOVASCULAR RISK REPORTS 2017. [DOI: 10.1007/s12170-017-0553-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Thrombophilia risk is not increased in children after perinatal stroke. Blood 2017; 129:2793-2800. [DOI: 10.1182/blood-2016-11-750893] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Accepted: 02/20/2017] [Indexed: 11/20/2022] Open
Abstract
Key Points
Thrombophilia in children with perinatal stroke is rare, with rates similar to those in the normal population. Routine testing in childhood is not indicated.
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Moriarty PM, Tennant H, Sehar N, Denney L, Luna P, Perez-Marques F, Panchal A, Abraham M, Leever J. Case report of male child with elevated lipoprotein (a) leading to acute ischemic stroke. J Clin Apher 2017; 32:574-578. [PMID: 28139007 DOI: 10.1002/jca.21525] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 12/30/2016] [Accepted: 01/03/2017] [Indexed: 01/04/2023]
Abstract
Acute ischemic stroke (AIS) in children is rare with almost 40% diagnosed as cryptogenic. One possible mechanism associated with AIS is an elevated Lipoprotein (a) [Lp(a)] level. Here, we discuss the case of an 11-year old boy who presented with multiple thrombotic strokes secondary to elevated Lp(a), which was identified as the only risk factor and immediately treated with lipoprotein apheresis (LA). Eighteen months post-AIS, he is still receiving LA treatments and has made remarkable progress in his recovery without another cerebrovascular event.
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Affiliation(s)
- Patrick M Moriarty
- Division of Clinical Pharmacology, University of Kansas Medical Center, Kansas City, Kansas, USA.,Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Heather Tennant
- Division of Clinical Pharmacology, University of Kansas Medical Center, Kansas City, Kansas, USA.,Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Nandhini Sehar
- Division of Clinical Pharmacology, University of Kansas Medical Center, Kansas City, Kansas, USA.,Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Lauryn Denney
- Division of Clinical Pharmacology, University of Kansas Medical Center, Kansas City, Kansas, USA.,Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Paola Luna
- Department of Pediatrics, University of Kansas Medical Center, Kansas City, Kansas, USA
| | | | - Apurva Panchal
- Department of Pediatrics, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Michael Abraham
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - John Leever
- Department of Radiology, University of Kansas Medical Center, Kansas City, Kansas, USA
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Beheshtian A, Shitole SG, Segal AZ, Leifer D, Tracy RP, Rader DJ, Devereux RB, Kizer JR. Lipoprotein (a) level, apolipoprotein (a) size, and risk of unexplained ischemic stroke in young and middle-aged adults. Atherosclerosis 2016; 253:47-53. [PMID: 27575936 PMCID: PMC5181117 DOI: 10.1016/j.atherosclerosis.2016.08.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 08/02/2016] [Accepted: 08/18/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND AIMS Circulating lipoprotein (a) [Lp(a)] level relates inversely to apolipoprotein (a) [apo(a)] size. Both smaller apo(a) isoforms and higher Lp(a) levels have been linked to coronary heart disease and stroke, but their independent contributions are less well defined. We examined the role of Lp(a) in younger adults with cryptogenic stroke. METHODS Lp(a) and apo(a) isoforms were evaluated in a prospectively designed case-control study of patients with unexplained ischemic stroke and stroke-free controls, ages 18 to 64. Serum Lp(a) was measured among 255 cases and 390 controls with both apo(a)-size independent and dependent assays. Apo(a) size was determined by agarose gel electrophoresis. RESULTS Cases and controls were similar in socio-demographic characteristics, but cases had more hypertension, diabetes, smoking, and migraine with aura. In race-specific analyses, Lp(a) levels showed positive associations with cryptogenic stroke in whites, but not in the smaller subgroups of blacks and Hispanics. After full adjustment, comparison of the highest versus lowest quartile in whites was significant for apo(a)-size-independent (OR = 2.10 [95% CI = 1.04, 4.27], p = 0.040), and near-significant for apo(a)-size-dependent Lp(a) (OR = 1.81 [95% CI = 0.95, 3.47], p = 0.073). Apo(a) size was not associated with cryptogenic stroke in any race-ethnic subgroup. CONCLUSIONS This study underscores the importance of Lp(a) level, but not apo(a) size, as an independent risk factor for unexplained ischemic stroke in young and middle-aged white adults. Given the emergence of effective Lp(a)-lowering therapies, these findings support routine testing for Lp(a) in this setting, along with further research to assess the extent to which such therapies improve outcomes in this population.
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Affiliation(s)
- Azadeh Beheshtian
- Department of Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY, USA
| | - Sanyog G Shitole
- Department of Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY, USA
| | - Alan Z Segal
- Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Dana Leifer
- Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Russell P Tracy
- Department of Pathology and Laboratory Medicine, University of Vermont College of Medicine, Burlington, VT, USA
| | - Daniel J Rader
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Jorge R Kizer
- Department of Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY, USA; Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA.
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González-Colmenero E, Suarez-Albo M, Concheiro-Guisan A. Role of lipoprotein (a) as a prothrombotic agent in the perinatal period. PEDIATRIC HEMATOLOGY ONCOLOGY JOURNAL 2016. [DOI: 10.1016/j.phoj.2016.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Lakshminarayan D, Elajami TK, Devabhaktuni S, Welty FK. Ischemic stroke in a young adult with extremely elevated lipoprotein(a): A case report and review of literature. J Clin Lipidol 2016; 10:1266-71. [PMID: 27678446 DOI: 10.1016/j.jacl.2016.06.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 06/28/2016] [Accepted: 06/30/2016] [Indexed: 11/16/2022]
Abstract
Lipoprotein(a) [Lp(a)] is an apolipoprotein(a) molecule bound to 1 apolipoprotein B-100. Elevated levels of Lp(a) are thought to be an independent risk factor for atherosclerosis and to promote thrombosis through incompletely understood mechanisms. We report a 34-year-old man with an ischemic stroke in the setting of an extremely high Lp(a) level-212 mg/dL. He developed severe carotid artery stenosis over a 6-year period and had thrombus formation post-carotid endarterectomy. To our knowledge, this case is unique because the Lp(a) is the highest reported level in a patient without renal disease. Moreover, this is the first reported case of the youngest individual with a stroke presumably related to development of carotid plaque over a 6-year period. The thrombotic complication after endarterectomy may have been related to the prothrombotic properties of Lp(a). Of note, the Lp(a) level did not respond to atorvastatin but did decrease 15% after aspirin 325 mg was added although his Lp(a) levels were variable, and it is not clear that this was cause and effect. This case highlights the need to better understand the relation between Lp(a) and vascular disease and the need to screen family members for elevated Lp(a). We also review treatment options to lower Lp(a) and ongoing clinical trials of newer lipid-lowering drugs that can also lower Lp(a).
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Affiliation(s)
- Dharshan Lakshminarayan
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA, USA
| | - Tarec K Elajami
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA, USA
| | - Suresh Devabhaktuni
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA, USA
| | - Francine K Welty
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA, USA.
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Lipoprotein (a) as a risk factor for ischemic stroke: a meta-analysis. Atherosclerosis 2015; 242:496-503. [PMID: 26298741 DOI: 10.1016/j.atherosclerosis.2015.08.021] [Citation(s) in RCA: 116] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 07/11/2015] [Accepted: 08/13/2015] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Lipoprotein (a) [Lp(a)] harbors atherogenic potential but its role as a risk factor for ischemic stroke remains controversial. We conducted a meta-analysis to determine the relative strength of the association between Lp(a) and ischemic stroke and identify potential subgroup-specific risk differences. METHODS A systematic search using the MeSH terms "lipoproteins" OR "lipoprotein a" AND "stroke" was performed in PubMed and ScienceDirect for case-control studies from June 2006 and prospective cohort studies from April 2009 until December 20th 2014. Data from eligible papers published before these dates were reviewed and extracted from previous meta-analyses. Studies that assessed the relationship between Lp(a) levels and ischemic stroke and reported generic data-i.e. odds ratio [OR], hazard ratio, or risk ratio [RR]-were eligible for inclusion. Studies that not distinguish between ischemic and hemorrhagic stroke and transient ischemic attack were excluded. Random effects meta-analyses with mixed-effects meta-regression were performed by pooling adjusted OR or RR. RESULTS A total of 20 articles comprising 90,904 subjects and 5029 stroke events were eligible for the meta-analysis. Comparing high with low Lp(a) levels, the pooled estimated OR was 1.41 (95% CI, 1.26-1.57) for case-control studies (n = 11) and the pooled estimated RR was 1.29 (95% CI, 1.06-1.58) for prospective studies (n = 9). Sex-specific differences in RR were inconsistent between case-control and prospective studies. Study populations with a mean age of ≤55 years had an increased RR compared to older study populations. Reported Lp(a) contrast levels and ischemic stroke subtype significantly contributed to the heterogeneity observed in the analyses. CONCLUSION Elevated Lp(a) is an independent risk factor for ischemic stroke and may be especially relevant for young stroke patients. Sex-specific risk differences remain conflicting. Further studies in these subgroups may be warranted.
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McNeal CJ. Lipoprotein(a): Its relevance to the pediatric population. J Clin Lipidol 2015; 9:S57-66. [PMID: 26343213 DOI: 10.1016/j.jacl.2015.07.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Revised: 06/09/2015] [Accepted: 07/14/2015] [Indexed: 11/26/2022]
Abstract
Lipoprotein(a) (Lp(a)) is a highly atherogenic and heterogeneous lipoprotein that is inherited in an autosomal codominant trait. A unique aspect of this lipoprotein is that it is fully expressed by the first or second year of life in children, a pattern that is distinctly different from other lipoproteins, which typically only reach adult levels after adolescence. Despite decades of research, Lp(a) metabolism is still poorly understood but what is abundantly clear is that it is an independent risk factor for atherosclerotic cardiovascular disease (ASCVD). The Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents does not recommend measuring Lp(a) levels as part of routine screening except in youth with an ischemic or hemorrhagic stroke or youth with a parental history of ASCVD not explained by classical risk factors. One of the reasons that both the pediatric and adult guidelines fail to include this lipoprotein as part of routine lipid screening is the absence of data to show that lowering Lp(a) will reduce current or future ASCVD risk independently of low-density lipoprotein cholesterol (LDL-C) lowering. The cholesterol carried by Lp(a) is included in the low-density lipoprotein cholesterol measurement, but a separate test is used to measure the lipoprotein mass and/or cholesterol carried only by Lp(a). Because levels seem to be largely under genetic control, studies of lifestyle modification have been inconclusive although one study in obese children showed a decrease in the Lp(a) level comparable with the favorable effect on other lipids. The most compelling data regarding the importance of Lp(a) in the pediatric population are the increased risk associated with arterial ischemic stroke, a risk that is comparable with that associated with antiphospholipid antibodies or protein C deficiency. Although no specific pharmaceutical treatments are recommended to lower Lp(a) levels in youth, it is vitally important to educate youth and their parents about the excessive risk associated with this lipoprotein and the need to avoid the acquisition of other lifestyle-related risk factors such as smoking, excess weight, and physical inactivity to preserve more ideal cardiovascular health in adulthood.
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Affiliation(s)
- Catherine J McNeal
- Division of Cardiology, Department of Internal Medicine, Baylor Scott & White Health, Temple, TX, USA.
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Sultan S, Schupf N, Dowling M, DeVeber G, Kirton A, Elkind MSV. Predictors of cholesterol and lipoprotein(a) testing in children with arterial ischemic stroke. J Stroke Cerebrovasc Dis 2014; 23:2405-13. [PMID: 25174567 DOI: 10.1016/j.jstrokecerebrovasdis.2014.05.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Revised: 05/05/2014] [Accepted: 05/19/2014] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Professional societies recommend screening lipids in healthy children. Dyslipidemia and elevated lipoprotein(a) are risk factors for adult cardiovascular disease and stroke. Their role in childhood arterial ischemic stroke is unexplored. Inconsistencies in testing limit analysis of existing lipid data. The objective of this study is to identify predictors and modifiable barriers to lipid testing in pediatric stroke. METHODS In this cross-sectional analysis, children (28 days-18 years) with arterial ischemic stroke were identified from the International Pediatric Stroke Study registry (January 2003-April 2012). Analyzed predictors of recorded lipid or lipoprotein a (Lp(a)) testing were age, sex, race, ethnicity, body mass index (BMI) category, other stroke risk factors, country, US region, and recurrent thrombosis. RESULTS Among 1652 participants (median, 6 years [interquartile range, 1.7-12.7]; 59.0% male; 40.8% white; 7.0% black), at least 1 lipid parameter or Lp (a) was available for 461 (27.9%). Compared with infants, testing was incrementally higher for older age categories. Compared with whites, testing was lower in blacks (adjusted odds ratio [OR], .5; 95% confidence interval [CI], .4-.5; P < .0001). Hispanic ethnicity only predicted testing within the United States (OR, 2.2; 95% CI, 1.4-3.4; P = .001]. Testing was lower in the United States and Australia and higher in Chile. Any thrombotic recurrence and recurrent symptomatic arterial ischemic stroke were associated with testing, unlike male sex, BMI, other stroke risk factors, and region in the United States. CONCLUSIONS Only a quarter of children with stroke had recorded lipid testing. Older age, white race, and recurrence predicted testing. In future study adjusting for these predictors may be necessary. Standardized lipid testing in children with arterial ischemic stroke may further our understanding of this potential risk factor.
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Affiliation(s)
- Sally Sultan
- Department of Neurology, College of Physicians and Surgeons, Columbia University, New York, New York.
| | - Nicole Schupf
- Taub Institute for Research on Alzheimer's disease and the Aging Brain, Columbia University, New York, New York; Gertrude H Sergievsky Center, Columbia University, New York, New York; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Michael Dowling
- Division of Pediatric Neurology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Gabrielle DeVeber
- Division of Neurology and Labatt Family Heart Centre, Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Adam Kirton
- Calgary Pediatric Stroke Program, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Mitchell S V Elkind
- Department of Neurology, College of Physicians and Surgeons, Columbia University, New York, New York; Gertrude H Sergievsky Center, Columbia University, New York, New York; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
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