Table I.
Recommendations for the diagnosis and management of elevated Lp(a) levels. Adapted from [4]
| Recommendation | Class |
|---|---|
| If the Lp(a) level is unknown, consider Lp(a) measurement: | |
| at least once in the lifetime of every adult | I |
| when statin treatment is ineffective | IIa |
| in patients with premature ASCVD | IIa |
| in high-risk patients with ASCVD | IIb |
| in patients with familial hypercholesterolemia | IIb |
| If the Lp(a) level is known, consider Lp(a) re-measurement: | |
| in women after the age of 50 years | I |
| when the initial Lp(a) level was 30–50 mg/dl (75–125 nmol/l) | IIb |
| in patients who developed kidney disease, especially nephrotic syndrome | IIb |
| in patients with ASCVD and elevated baseline Lp(a) level | IIb |
| While determining the Lp(a) level: | |
| use an assay which is insensitive to the apo(a) isoform size and reports the molar concentration (nmol/l) of Lp(a) | I |
| If the Lp(a) level is > 10 mg/dl (> 25 nmol/l): | |
| reassess the patient’s cardiovascular risk | I |
| recommend lifestyle changes | I |
| recommend pharmacological optimization of cardiovascular risk factors and conditions affecting Lp(a) levels | I |
| If the Lp(a) level is > 30 mg/dl (> 75 nmol/l), additionally: | |
| consider Lp(a) measurement in the patient’s relatives | IIa |
| consider evaluation of the family history of (premature) ASCVD | IIa |
| consider apo(a) isoform size and genetic testing | IIb |
| consider the use of pitavastatin | IIb |
| consider the replacement of high-intensity statin monotherapy with a combination of a lower-dose statin and ezetimibe | IIb |
| consider initiation of triple therapy with a statin, ezetimibe, and PCSK9 modulator, if required to achieve the LDL-C goal according to the patient’s global cardiovascular risk | IIb |
| If the Lp(a) level is > 50 mg/dl (> 125 nmol/l), additionally: | |
| intensify statin treatment if the patient is on a low-/moderate-intensity statin | I |
| add ezetimibe if the patient is on a maximum-dose statin | I |
| consider the addition of a PCSK9 modulator, if the patient is on a combination of a statin and ezetimibe | IIa |
| If the Lp(a) level is > 60 mg/dl (> 150 nmol/l), additionally: | |
| consider lipoprotein apheresis if the patient experiences ASCVD progression despite optimization of all other modifiable cardiovascular risk factors | IIa |
Apo(a) – apolipoprotein (a), ASCVD – atherosclerotic cardiovascular disease, LDL-C – low-density lipoprotein cholesterol, Lp(a) – lipoprotein (a), PCSK9 – proprotein convertase subtilisin/kexin type 9.