Lipoprotein(a) and coronary artery disease: The need for universal screening - A case-based review

Atherosclerosis cardiovascular disease (ASCVD), especially coronary artery disease (CAD), remains the leading cause of death worldwide, with several well-identified risk factors. This case report presents a premenopausal female with low calculated ASCVD risk, hypertension, elevated lipoprotein(a) [Lp(a)], and clinically significant CAD.

A 44-year-old premenopausal White female with controlled stage 2 hypertension, and overall low calculated 10-year ASCVD risk, was found to have severe CAD. She presented to the clinic with worsening chest discomfort during exertion and was diagnosed with a heavily calcified proximal left anterior descending artery stenosis, necessitating percutaneous coronary intervention.

The global prevalence of elevated Lp(a) >50 mg/dL is around 1.43 billion. Elevated lipoprotein(a) is now recognized, based on the preponderance of the evidence, by several international scientific statements as an independent risk factor for ASCVD, including CAD. Nevertheless, the current 2018 American College of Cardiology (ACC) and American Heart Association (AHA) multi-society guideline on the Management of Blood Cholesterol only classifies Lp(a) as a risk enhancer. This recommendation, along with the lack of approved pharmacotherapy has contributed to limited testing in current United States clinical practice (<1 % for the general population). Furthermore, the inadequate assessment of Lp(a) may lead to an underestimation of ASCVD risk.

This case highlights the shortcomings of inadequate assessment of Lp(a) leading to the underestimation of cardiovascular risk. Accordingly, with multiple recent international scientific statements, clinicians should universally screen for elevated Lp(a). In the future, investigational therapies for lowering Lp(a) may be crucial for improving patient outcomes.