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Lipoprotein (a) Testing in Patients With Atherosclerotic Cardiovascular Disease in 5 Large US Health Systems
Nishant P Shah1,2, Hillary Mulder2, Elizabeth Lydon2
1Division of Cardiology Duke University Hospital Durham NC USA.
Insights
Lipoprotein (a) testing is infrequent in atherosclerotic cardiovascular disease patients, showing disparities in older or Black individuals. Testing increases lipid-lowering therapy initiation, highlighting a need for greater awareness.
Area of Science:
- Cardiology
- Clinical Lipidology
- Public Health
Background:
- Lipoprotein (a) is a significant independent risk factor for atherosclerotic cardiovascular disease (ASCVD).
- Current lipoprotein (a) testing practices are variable, with limited understanding of influencing factors and impact on clinical management.
- Disparities in testing may exist, affecting patient care and outcomes.
Purpose of the Study:
- To investigate factors associated with lipoprotein (a) testing in a large ASCVD cohort.
- To determine if lipoprotein (a) testing influences lipid-lowering therapy initiation and management.
- To identify potential disparities in testing rates among different patient demographics.
Main Methods:
- Retrospective analysis of electronic medical records from 5 health systems (2019-2021).
- Inclusion of a large ASCVD cohort (595,984 patients).
- Multivariable regression modeling to identify factors associated with lipoprotein (a) testing and its impact on therapy.
Main Results:
- Only 0.4% of the ASCVD cohort underwent lipoprotein (a) testing.
- Older patients and Black individuals were less likely to be tested.
- Testing was associated with increased initiation of statin, ezetimibe, and PCSK9 inhibitor therapies, especially with elevated levels.
Conclusions:
- Lipoprotein (a) testing is underutilized in ASCVD patients, with notable demographic disparities.
- Lipoprotein (a) testing, irrespective of level, correlates with increased initiation of lipid-lowering therapies.
- Elevated lipoprotein (a) levels prompt greater use of non-statin therapies, underscoring the need for awareness and inclusive testing strategies.
Background:
Lipoprotein (a) is an independent risk factor for atherosclerotic cardiovascular disease. However, lipoprotein (a) testing remains variable and it is unclear what factors influence testing and if testing changes clinical management.
Methods And Results:
A retrospective study using electronic medical record data from 5 health systems identified an atherosclerotic cardiovascular disease cohort divided into those with and without a lipoprotein (a) test between 2019 and 2021. Baseline characteristics and lipid-lowering therapy patterns were assessed. Multivariable regression modeling was used to determine factors associated with lipoprotein (a) testing. Among 595 684 patients with atherosclerotic cardiovascular disease, only 2587 (0.4%) were tested for lipoprotein (a). Those who were older or Black individuals were less likely to have lipoprotein (a) testing, while those with familial hypercholesterolemia, ischemic stroke/transient ischemic attack, peripheral artery disease, prior lipid-lowering therapy, or low-density lipoprotein cholesterol ≥130 mg/dL were more likely to be tested. Those with a lipoprotein (a) test, regardless of the lipoprotein (a) value, were more frequently initiated on any statin therapy (30.3% versus 10.6%, P < 0.001), ezetimibe (7.65% versus 0.8%, P < 0.001), or proprotein convertase substilisin/kexin type 9 inhibitor (6.7% versus 0.3%, P < 0.001) compared with those without a test. Those with an elevated lipoprotein (a) level more frequently initiated ezetimibe (11.5% versus 5.9%, P < 0.001) or proprotein convertase substilisin/kexin type 9 inhibitor (10.9% versus 4.8%, P < 0.001).
Conclusions:
Lipoprotein (a) testing in patients with atherosclerotic cardiovascular disease is infrequent, with evidence of disparities among older or Black individuals. Testing for lipoprotein (a), regardless of level, is associated with greater initiation of any lipid-lowering therapy, while elevated lipoprotein (a) is associated with greater initiation of nonstatin lipid-lowering therapy. There is a critical need for multidisciplinary and inclusive approaches to raise awareness for lipoprotein (a) testing, and its implications on management.
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