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Lipoprotein(a), C-Reactive Protein, and Cardiovascular Risk in Primary and Secondary Prevention Populations
Aeron M Small1,2,3, Ashley Pournamdari4,5, Giorgio E M Melloni6
1Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
Insights
Elevated lipoprotein(a) (Lp[a]) increases cardiovascular risk independently of inflammation. This finding holds true for both primary and secondary prevention, highlighting Lp[a] as a key risk factor for atherosclerotic cardiovascular disease (ASCVD).
Area of Science:
- Cardiovascular Medicine
- Lipidology
- Epidemiology
Background:
- Elevated lipoprotein(a) (Lp[a]) is a recognized risk factor for atherosclerotic cardiovascular disease (ASCVD).
- Conflicting evidence exists regarding whether Lp[a] confers cardiovascular risk solely in the presence of inflammation.
Purpose of the Study:
- To determine if Lp[a] is associated with cardiovascular risk independently of high-sensitivity C-reactive protein (hs-CRP).
- To investigate this association in both primary and secondary prevention populations.
Main Methods:
- A cohort study utilizing data from three distinct cohorts: UK Biobank (population-based), FOURIER trial, and SAVOR-TIMI 53 trial (randomized clinical trials).
- Analysis included assessment of baseline plasma Lp(a) and hs-CRP levels.
- Cox proportional hazard models were used to evaluate the risk of major adverse cardiovascular events (MACE), including cardiovascular death, myocardial infarction (MI), ischemic stroke, and peripheral artery disease (PAD).
Main Results:
- In the UK Biobank cohort (n=357,220), higher Lp(a) levels were associated with increased risk of MACE, MI, ischemic stroke, and PAD, irrespective of hs-CRP levels (P for interaction ≥ .80).
- In the FOURIER and SAVOR trials (n=34,020), higher Lp(a) was also linked to increased risk of MACE, MI, and PAD, independent of hs-CRP levels (P for interaction ≥ .16).
- Hazard ratios for MACE per 50-nmol/L higher Lp[a] ranged from 1.02 to 1.05 across different hs-CRP strata and cohorts.
Conclusions:
- Elevated Lp(a) is associated with a significantly increased risk of MACE, MI, and PAD in both primary and secondary prevention settings.
- This association persists regardless of baseline hs-CRP levels, suggesting Lp[a] is an independent cardiovascular risk factor.
- These findings underscore the importance of considering Lp[a] levels in cardiovascular risk assessment and management.
Importance:
Elevated lipoprotein(a) (Lp[a]) is a putative causal risk factor for atherosclerotic cardiovascular disease (ASCVD). There are conflicting data as to whether Lp(a) may increase cardiovascular risk only in the presence of concomitant inflammation.
Objective:
To investigate whether Lp(a) is associated with cardiovascular risk independent of high-sensitivity C-reactive protein (hs-CRP) in both primary and secondary prevention populations.
Design, Setting, And Participants:
This cohort study uses data from 3 distinct cohorts, 1 population-based cohort and 2 randomized clinical trials. Participants included individuals from the UK Biobank (data from 2006-2010) without prevalent ASCVD, participants in the FOURIER (TIMI 59) trial (data from 2013-2017) who had baseline Lp(a) and hs-CRP data, and participants in the SAVOR-TIMI 53 trial (data from 2010-2013) who had prevalent ASCVD and baseline values for Lp(a) and hs-CRP. The data analysis took place from November 2022 to November 2023.
Exposure:
Baseline plasma Lp(a), considered either as a continuous variable or dichotomized at 125 nmol/L.
Main Outcomes And Measures:
Risk of major adverse cardiovascular events (MACE) (composite of cardiovascular death, myocardial infarction [MI], or ischemic stroke), the individual MACE components, and peripheral artery disease (PAD).
Results:
Among 357 220 individuals in the UK Biobank without prevalent ASCVD, 232 699 (65%) had low hs-CRP (<2 mg/L), and 124 521 (35%) had high hs-CRP (≥2 mg/L) values. In a Cox proportional hazard model adjusted for ASCVD risk factors, higher Lp(a) was associated with increased cardiovascular risk regardless of baseline hs-CRP value for MACE (hs-CRP ≥2 mg/L: hazard ratio [HR] per 50-nmol/L higher Lp[a], 1.05; 95% CI, 1.04-1.07; P < .001; for hs-CRP <2 mg/L: HR, 1.05; 95% CI, 1.04-1.07; P < .001; P = .80 for interaction), as well as MI, ischemic stroke, and PAD individually. Among 34 020 individuals in the FOURIER and SAVOR trials with baseline cardiometabolic disease, there were 17 643 (52%) with low and 16 377 (48%) with high baseline hs-CRP values. In Cox proportional hazard models using aggregated data from FOURIER and SAVOR, higher baseline Lp(a) was associated with increased cardiovascular risk regardless of baseline hs-CRP for MACE (hs-CRP ≥2 mg/L: HR per 50-nmol/L higher Lp[a], 1.02; 95% CI, 1.00-1.05; P = .04; hs-CRP <2 mg/L: HR, 1.05; 95% CI, 1.02-1.08; P < .001; P = .16 for interaction), MI, and PAD.
Conclusions And Relevance:
In this study, higher levels of Lp(a) were associated with MACE, MI, and PAD in both primary and secondary prevention populations regardless of baseline hs-CRP value.
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