Lipoprotein(a), Cardiovascular Disease, andContemporary Management

Elevated lipoprotein(a) (Lp[a]) is a causal genetic risk factor for cardiovascular disease. To determine ifcurrent evidence supports both screening and treatment for elevated Lp(a) in high-risk patients, an English-language search of PubMed and MEDLINE was conducted. In population studies, there is a continuousassociation between Lp(a) concentrations and cardiovascular risk, with synergistic effects when low-densitylipoprotein (LDL) is also elevated. Candidates for Lp(a) screening include patients with a personal or familyhistory of premature cardiovascular disease, familial hypercholesterolemia, recurrent cardiovascular events,or inadequate LDL cholesterol (LDL-C) responses to statins. Given the comparative strength of clinical ev-idence, reducing LDL-C to the lowest attainable value with a high-potency statin should be the primary focusof lipid-modifying therapies. If the Lp(a) level is 30 mg/dL or higher in a patient who has the aforementionedcharacteristics plus residual LDL-C elevations ( 70-100 mg/dL) despite maximum-potency statins orcombination statin therapy, the clinician may consider adding niacin (up to 2 g/d). If, after these in-terventions, the patient has progressive coronary heart disease (CHD) or LDL-C levels of 160-200 mg/dL orhigher, LDL apheresis should be contemplated. Although Lp(a) is a major causal risk factor for CHD, nocurrently available controlled studies have suggested that lowering it through either pharmacotherapy or LDLapheresis specifically and significantly reduces coronary risk. Further research is needed to (1) optimizemanagement in order to reduce CHD risk associated with elevated Lp(a) and (2) determine what other in-termediate- or high-risk groups might benefit from Lp(a) screening.