Comparison of Lipoprotein(a) levels between elderly and middle-aged men with coronary artery disease

The influence of lipoprotein(a) on aortic valve calcification in patients undergoing transcatheter aortic valve replacement

BACKGROUND

Elevated levels of lipoprotein(a) (Lp[a]) have been recognized as substantial risk factors for cardiovascular disease and aortic stenosis (AS). However, the specific role of Lp(a) in promoting aortic valve calcification (AVC) and influencing mortality in elderly, multimorbid patients undergoing transcatheter aortic valve replacement (TAVR) remains unclear and warrants further investigation.

METHODS

A retrospective analysis was conducted on all consecutive patients who underwent TAVR between August 2019 and June 2020 at our clinic. Patients with missing data or prior aortic valve replacement were excluded. The study cohort was stratified based on an Lp(a) threshold of 60 mg/dl according to guidelines for lipoprotein apheresis in UK and Germany.1,2 RESULTS: In total, 454 patients were included into the analysis. Mean age was 81 ± 6 years and patients presented with a notable cardiovascular risk profile. Lp(a) values ≥ 60 mg/dl were detected in 102 (22.5%) patients, while 352 (77.5%) had Lp(a) values < 60 mg/dl. The median calcium volume of the total cohort was 894.5 [570.8; 1,382.8] mm2. No significant difference was observed between the groups (p = 0.83). Furthermore, Lp(a) did not emerge as a statistically significant predictor of calcium levels before TAVR. Notably, male gender (B = 404.11, p < 0.001) and mean trans-valvular pressure gradient (B = 15.64, p < 0.001) were identified as the strongest coefficients within the robust regression analysis. Log-rank tests indicated no prognostic utility of Lp(a) for 30-day all-cause mortality (p = 0.30) or 40 months long-term all-cause mortality (p = 0.60).

CONCLUSION

Lp(a) might not exert a significant effect on calcification levels or all-cause mortality in patients undergoing TAVR. Despite the study's highly selected population, these results align with current research, supporting the assumption that the influence of Lp(a) may be confined to the early stages of AS and its progression.

Risk Factors for Early-Onset Versus Late-Onset Coronary Heart Disease (CHD): Systematic Review and Meta-Analysis

AIM

We aimed to systematically compare literature on prevalence of modifiable and non-modifiable risk factors for early compared to late-onset coronary heart disease (CHD).

METHODS

PubMed, CINAHL, Embase, and Web of Science databases were searched (review protocol registered in PROSPERO CRD42020173216). Study quality was assessed using the National Heart, Lung and Blood Institute tool for observational and case-control studies. Review Manager 5.3 was used for meta-analysis. Effect sizes were expressed as odds ratio (OR) and mean differences (MD)/standardised MD (SMD) with 95% confidence intervals (CI) for categorical and continuous variables.

RESULTS

Individuals presenting with early-onset CHD (age <65 years) compared to late-onset CHD had higher mean body mass index (MD 1.07 kg/m2; 95% CI 0.31-1.83), total cholesterol (SMD 0.43; 95% CI 0.23-0.62), low-density lipoprotein (SMD 0.26; 95% CI 0.15-0.36) and triglycerides (SMD 0.50; 95% CI 0.22-0.68) with lower high-density lipoprotein-cholesterol (SMD 0.26; 95% CI -0.42--0.11). They were more likely to be smokers (OR 1.76, 95% CI 1.39-2.22) and have a positive family history of CHD (OR 2.08, 95% CI 1.74-2.48). They had lower mean systolic blood pressure (MD 4.07 mmHg; 95% CI -7.36--0.78) and were less likely to have hypertension (OR 0.47, 95% CI 0.39-0.57), diabetes mellitus (OR 0.56, 95% CI 0.51-0.61) or stroke (OR 0.31, 95% CI 0.24-0.42).

CONCLUSION

A focus on weight management and smoking cessation and aggressive management of dyslipidaemia in young adults may reduce the risk of early-onset CHD.

Lipoprotein(a) As a Risk Factor in a Cohort of Hospitalised Cardiovascular Patients: A Retrospective Clinical Routine Data Analysis

INTRODUCTION

Lipoprotein(a) (Lp(a)) is a well-recognised risk factor for ischemic heart disease (IHD) and calcific aortic valve stenosis (AVS).

METHODS

A retrospective observational study of Lp(a) levels (mg/dL) in patients hospitalised for cardiovascular diseases (CVD) in our clinical routine was performed. The Lp(a)-associated risk of hospitalisation for IHD, AVS, and concomitant IHD/AVS versus other non-ischemic CVDs (oCVD group) was assessed by means of logistic regression.

RESULTS

In total of 11,767 adult patients, the association with Lp(a) was strongest in the IHD/AVS group (e^β = 1.010, p < 0.001), followed by the IHD (e^β = 1.008, p < 0.001) and AVS group (e^β = 1.004, p < 0.001). With increasing Lp(a) levels, the risk of IHD hospitalisation was higher compared with oCVD in women across all ages and in men aged ≤75 years. The risk of AVS hospitalisation was higher only in women aged ≤75 years (e^β = 1.010 in age < 60 years, e^β = 1.005 in age 60-75 years, p < 0.05).

CONCLUSIONS

The Lp(a)-associated risk was highest for concomitant IHD/AVS hospitalisations. The differential impact of sex and age was most pronounced in the AVS group with an increased risk only in women aged ≤75 years.

Identifying the Biomarker Profile of Pre-Frail and Frail People: A Cross-Sectional Analysis from UK Biobank

OBJECTIVE

This study aimed to compare the biomarker profile of pre-frail and frail adults in the UK Biobank cohort by sex.

METHODS

In total, 202,537 participants (67.8% women, aged 37 to 73 years) were included in this cross-sectional analysis. Further, 31 biomarkers were investigated in this study. Frailty was defined using a modified version of the Frailty Phenotype. Multiple linear regression analyses were performed to explore the biomarker profile of pre-frail and frail individuals categorized by sex.

RESULTS

Lower concentrations of apoA1, total, LDL, and HDL cholesterol, albumin, eGFRcys, vitamin D, total bilirubin, apoB, and testosterone (differences ranged from -0.30 to -0.02 per 1-SD change), as well as higher concentrations of triglycerides, GGT, cystatin C, CRP, ALP, and phosphate (differences ranged from 0.01 to 0.53 per 1-SD change), were identified both in pre-frail and frail men and women. However, some of the associations differed by sex. For instance, higher rheumatoid factor and urate concentrations were identified in pre-frail and frail women, while lower calcium, total protein, and IGF-1 concentrations were identified in pre-frail women and frail women and men. When the analyses were further adjusted for CRP, similar results were found.

CONCLUSIONS

Several biomarkers were linked to pre-frailty and frailty. Nonetheless, some of the associations differed by sex. Our findings contribute to a broader understanding of the pathophysiology of frailty as currently defined.

The relationship between the level of Lр(а) and the prevalence of atherosclerosis among young patients

Background. Hyperlipoproteinemia (a) is an independent and cause risk factor for atherosclerotic cardiovascular diseases (ASCVD). The correlation between lipoprotein (a) Lp(a) and inflammation in the vessel wall was actively studied during the past few years. C-reactive protein (CRP) plays an important role in ASCVD. Aim. To analyze the relationship between hyperlipoproteinemia (a), inflammatory markers, and the early development of stenosing atherosclerosis (AS) in several vascular pools. Materials and methods. 76 patients, 55 men aged 18 to 55 years and 21women 18 to 60 years, with the results of instrumental examination of coronary, carotid and lower extremities vascular pools were enrolled. Three groups: with stenosing (50%) AS of only one (group 1, n=29); two or three (group 2, n=21) vascular pools. 26 patients without coronary heart disease and AS were included in the control group. All patients in groups 1 and 2 and 65% of those in the control group took statins. The concentrations of Lp(a), CRP, lipids and blood count were determined. Results. The patients of the three groups did not differ in age. In the groups with AS (79% in group 1 and 85% in group 2), there were more men (relative to 54% in the control group). Diabetes mellitus was more common only in patients with multifocal AS. The absolute number of blood monocytes and leukocytes, the neutrophil-lymphocyte ratio, as well as Lp(a) level were higher in patients of groups 1 and 2 relative to the control. The maximum Lp(a) level (median [25%; 75%]) was observed in patients with lesions of two or more vascular pools vs the control group (49 [4; 96] mg/dL, vs 10 [4; 21] mg/dL, p=0.02). The CRP level was significant elevated in patients from group 2 7.2 [4.0; 9.7] mg/L, relative to group 1 2.5 [1.0; 4.7] mg/L, and the control group 2.9 [1.2; 4.9] mg/L, p0.05. The Lp(a) and CRP concentration, or the presence of diabetes mellitus in patients, regardless of other risk factors, were associated with severe stenosing AS in young and middle age. Conclusion. An elevated concentration of Lp(a) (30 mg/dL) determines the presence of both isolated and multifocal stenosing AS in the examined patients. A simultaneous increase in the concentration of both Lp(a) and CRP, as well as the presence of diabetes mellitus, are associated with the premature development of stenosing atherosclerotic lesions in several vascular regions at once. Measurement of these predictors in young and middle-aged patients makes it possible to use them as biochemical markers to assess the likelihood of multifocal lesions of the vascular pool.

Elevated Lipoprotein A in South Asians and the Associated Risk of Cardiovascular Disease: A Systematic Review

BACKGROUND

South Asians have a premature risk of cardiovascular disease and increased lipoprotein A which enhances their risk.

METHODS

This systematic review evaluates the role of elevated lipoprotein A in cardiovascular disease risk for South Asians. It discusses the pathophysiology, clinical studies, and treatment of elevated lipoprotein A using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses method.

RESULTS

A total of 72 articles was incorporated which consisted of clinical studies, case-control and cohort studies, meta-analysis, reviews, and editorials. Cardiovascular disease and myocardial infarction occurs prematurely in South Asians, which is further enhanced with an elevated lipoprotein A.

CONCLUSIONS

South Asians with an elevated lipoprotein A have an increased risk of coronary artery disease so they should have early enactment of lifestyle modification and aggressive medical management.

Lipoprotein(a) metabolism: potential sites for therapeutic targets

Lipoprotein(a) [Lp(a)] resembles low-density lipoprotein (LDL), with an LDL lipid core and apolipoprotein B (apoB), but contains a unique apolipoprotein, apo(a). Elevated Lp(a) is an independent risk factor for coronary and peripheral vascular diseases. The size and concentration of plasma Lp(a) are related to the synthetic rate, not the catabolic rate, and are highly variable with small isoforms associated with high concentrations and pathogenic risk. Apo(a) is synthesized in the liver, although assembly of apo(a) and LDL may occur in the hepatocytes or plasma. While the uptake and clearance site of Lp(a) is poorly delineated, the kidney is the site of apo(a) fragment excretion. The structure of apo(a) has high homology to plasminogen, the zymogen for plasmin and the primary clot lysis enzyme. Apo(a) interferes with plasminogen binding to C-terminal lysines of cell surface and extracellular matrix proteins. Lp(a) and apo(a) inhibit fibrinolysis and accumulate in the vascular wall in atherosclerotic lesions. The pathogenic role of Lp(a) is not known. Small isoforms and high concentrations of Lp(a) are found in healthy octogenarians that suggest Lp(a) may also have a physiological role. Studies of Lp(a) function have been limited since it is not found in commonly studied small mammals. An important aspect of Lp(a) metabolism is the modification of circulating Lp(a), which has the potential to alter the functions of Lp(a). There are no therapeutic drugs that selectively target elevated Lp(a), but a number of possible agents are being considered. Recently, new modifiers of apo(a) synthesis have been identified. This review reports the regulation of Lp(a) metabolism and potential sites for therapeutic targets.

21-Year-old male with severe coronary atherosclerosis

Coronary heart disease (CHD) is not limited to middle-aged and elderly individuals; when premature CHD develops in the younger population, it has distinct characteristics in terms of lipid profile, risk factors, and clinical presentation. The following describes a 21-year-old male who presented with stable angina, underwent a full cardiac workup, and was ultimately found to have multivessel CHD. In summary, the presence of mild dyslipidemia, high blood pressure, cigarette smoking, obesity, and a family history was sufficient to induce ischemic heart disease at such a young age. <Learning objective: This case report reveals an exceptionally young Caucasian man presenting with stable angina and found to have multivessel coronary disease. The patient received a coronary artery bypass surgery at just 21 years of age. He exhibits traditional risk factors of CHD; hypertension, dyslipidemia, cigarette smoking, and obesity. CHD may be more prevalent in the younger population than once was thought, and it is important that risk factor reduction starts in early in life.>.

Clinical profile, common thrombophilia markers and risk factors in 85 young Indian patients with arterial thrombosis

CONTEXT AND OBJECTIVE

Arterial thrombosis may occur consequent to hereditary thrombophilia and increased lipoprotein(a) [Lp(a)] and fibrinogen. Our aim was to study the prevalence of common thrombophilia markers in 85 consecutive cases of arterial thrombosis.

DESIGN AND SETTING

A retrospective study was conducted from 85 consecutive young patients treated as outpatients or admitted due to stroke or myocardial infarction at a tertiary care hospital.

METHODS

Eighty-five Indian patients (age < 45 years) presenting ischemic stroke (n = 48) or myocardial infarction (n = 37) and 50 controls were studied for seven thrombophilia markers including antithrombin (AT), factor V, protein C, protein S, activated protein C resistance (APC-R), fibrinogen and Lp(a). Functional assays for protein C, protein S, factor V and APC-R were performed using clotting-based methods. Semi-quantitative estimation of fibrinogen was done using Clauss's method and Lp(a) using immunoturbidimetry. Statistical analysis was done using the Epi Info 6 software.

RESULTS

Thirty-three samples (38.8%) tested positive for one or more thrombophilia markers. The three commonest abnormalities were elevated Lp(a) (20%), fibrinogen (17.6%) and low APC-R (14.2%). Low levels of protein C, protein S and AT were present in 4.7, 9.4 and 7% of the patients, respectively. Overall, the risk factor profile was: smoking (33%), positive family history (15.3%), hyperlipidemia (7%), hypertension, diabetes mellitus and obesity (2.3% each).

CONCLUSIONS

An association was found between low levels of protein C, protein S and AT and arterial thrombosis, but only elevated fibrinogen levels, smoking, positive family history and hyperlipidemia showed statistical significance.

Lipoprotein (a) in patients with psoriasis: associations with lipid profiles and disease severity

BACKGROUND

Lipoprotein (a) [Lp(a)] is a genetically determined molecule whose role has been implied in cardiovascular pathology, and whose levels have been reported to be elevated in patients with psoriasis. Aim To assess the serum levels of Lp(a) in patients with psoriasis, and to investigate the associations of Lp(a) with other lipids and with psoriasis severity.

METHODS

Thirty-four patients with psoriasis and 26 healthy control subjects took part in the study. Serum levels of Lp(a) and total, high density lipoprotein (HDL), low density lipoprotein (LDL), and very low density lipoprotein (VLDL) cholesterol fractions were measured in all participants. The levels of triglycerides and total cholesterol were measured using enzymatic colorimetric tests; HDL and LDL cholesterol concentrations were determined by precipitation methods; the VLDL concentration was calculated according to the formula: VLDL cholesterol = triglycerides/5.

RESULTS

Patients with psoriasis showed significantly higher serum levels of Lp(a) relative to controls. Even when controlling for normolipidemic vs. hyperlipidemic status, abnormal levels of Lp(a) (> 30 mg/dL) were observed significantly more often in patients than in controls. In both patients and controls, Lp(a) levels correlated positively with total and HDL cholesterol levels. In patients, Lp(a) levels correlated positively with psoriasis severity.

CONCLUSIONS

Lp(a) may be a factor contributing to an increased cardiovascular risk in patients with psoriasis. A pathogenetic link may exist between this lipoprotein and psoriatic pathophysiology.