The challenge of secondary cardiovascular prevention in very high Lipoprotein (a) level: a case report

While advances in technology and procedural techniques have significantly improved outcomes post-PCI, two pharmacological strategies have gained particular attention for their effectiveness in reducing long-term cardiovascular (CV) risk: anti-platelet therapies and lipid-lowering therapies (LLT). The 10-year recurrence risk for major CV events remains as high as 10-30%, due to various pathophysiological pathways collectively known as residual risk (RR), even with optimal CV risk factor management after acute coronary syndrome (ACS). RR includes factors such as elevated lipoprotein(a) [Lp(a)], triglycerides, pro-thrombotic states, hyperglycemia, and persistent subclinical arterial inflammation.

This case highlights the challenge of managing a patient with multiple recurrent cardiac ischaemic events and in-stent restenosis, despite good medical therapy and no other significant CV risk factors except for markedly elevated Lp(a) levels.

Three critical aspects of daily practice emerge from our observation. First, Lp(a) is a valuable parameter for CV risk stratification in primary prevention. Second, measurement of Lp(a) post-CV event may provide valuable information on the risk of ischaemic recurrence, influencing decisions regarding long-term dual anti-platelet therapy (DAPT). Finally, this case illustrates the importance of a multidisciplinary approach in managing patients with very high cardiovascular risk. Close collaboration between cardiologists and lipidologists facilitated the identification of a rare lipid disorder and the decision to pursue lipoprotein apheresis, an intensive but effective treatment option for lipid metabolism disorders lacking conventional medical therapy.