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In whom should Lp(a) be measured?
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all adults at least once in youth with a history of ischaemic stroke or a family history of premature ASCVD or high Lp(a) and no other identifiable risk factors. Cascade testing for high Lp(a) is recommended in the settings of FH, family history of (very) high Lp(a), and personal or family history of ASCVD.
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All individuals |
In each adult person. |
those with a personal or family history of premature ASCVD; those with first-degree relatives who have Lp(a) levels >200 nmol/L; patients with familial hypercholesterolemia; patients with calcific aortic valve stenosis those with borderline (but<15%) 10-year risk of a cardiovascular event.
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A relative indication for its measurement is family history of premature ASCVD |
Testing is reasonable in:
family history of first-degree relatives with premature ASCVD; premature ASCVD; primary severe hypercholesterolemia or suspected FH. very high risk of ASCVD to decide on PCSK9 inhibitor therapy.
Testing may be reasonable to:
Intermediate (7.5%–19.9%) 10-y ASCVD risk when the decision to use a statin is uncertain, to improve risk stratification in primary prevention. borderline (5%–7.4%) 10-y ASCVD risk when the decision to use a statin is uncertain, to improve risk stratification in primary prevention less-than-anticipated LDL-C lowering, despite good adherence to LDL-C lowering therapy family history of elevated Lp(a) calcific valvular aortic stenosis recurrent or progressive ASCVD, despite optimal lipid-lowering therapy
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How often?
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At least once to identify those with high cardiovascular risk |
Once in a person’s
lifetime as a part of the initial lipid screening |
At least once in a person’s lifetime |
Once, unless a secondary cause of Lp(a) elevation is suspected or specific treatment is instituted |
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Assay considerations
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Use of assays that are insensitive to apo(a) isoform and traceable to official reference materials. Measurement should be in molar units if available. If not, the units in which the assay is calibrated should be used for reporting. Rather than absolute values, clinical guidelines should consider using risk thresholds with ‘grey’ zones (e.g., 30–50 mg/dL) to either rule-in (≥50 mg/dL) or rule-out (<30 mg/dL) cardiovascular risk.
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using a method with minimized apo(a) isoform effects; results should be expressed in nmol/l; Conversion of mg/dL to nmol/L or vice versa should be discouraged. Currently only assays based on Denka reagents can be recommended.
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Recommended that an immunochemical assay calibrated against the WHO/IFCCLM secondary reference material should be used and reported in nmol/L. Conversion of Lp(a) values from mg/dL to nmol/L is not recommended.
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Risk threshold
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There is a linear and continuous relationship between Lp(a) levels and ASCVD risk. Risk thresholds with grey zones (e.g. 30–50 mg/dL; see above)
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180 mg/dL: often misunderstood as threshold but it is considered as a risk equivalent of heterozygous FH |
Risk increase:
Minor: 32–90 nmol/L;
Moderate: 90–200 nmol/L
High: 200–400 nmol/L
Very high: >400 nmol/L |
Lp(a) ≥50 mg/dL or ≥125 nmol/L constitutes a risk- enhancing factor, especially at higher levels of Lp(a) |
Lp(a) ≥50 mg/dL or ≥125 nmol/L |
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Management of patients with high Lp(a)
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Early risk factor management is recommended for elevated Lp(a), taking into account the absolute global cardiovascular risk and Lp(a) level. Among patients with high Lp(a), all cardiovascular risk factors should be comprehensively addressed as per guideline recommendations. Lipoprotein apheresis can be considered in patients with very high Lp(a) and progressive cardiovascular disease. An Lp(a) risk calculator is provided at: http://www.lpaclinicalguidance.com
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For all primary prevention patients with Lp(a) ≥50 mg/dL, earlier and more intensive health behavior modification counselling and management of other ASCVD risk factors is recommended FRS 5–9.9%: when LDL-C ≥3.5 mmol/L and Lp(a) ≥50 mg/dL: behavior modification and statin therapy; FRS 10–19.9% and Lp(a) ≥50 mg/dL: behavior modification and statin therapy
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In case of Lp(a) >90 nmol/L):
reducing overall atherosclerotic risk; controlling hyperlipidemia (desirable non-HDL cholesterol is <100 mg/dL); consideration of lipoprotein apheresis as per the HEART UK Lipoprotein apheresis statement.
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In case of Lp(a) >50 mg/dL:
In persons aged 40–75 y with a 10-y ASCVD risk of 7.5%–19.9%, it is reasonable to favor initiation of a moderate- or high-intensity statin in those with on-treatment LDL-C ≥70 mg/dL. In high-risk* or very-high-risk** patients, it is reasonable to consider more intensive LDL-C lowering. In very-high-risk** patients, taking a maximally tolerated statin, the addition of ezetimibe is reasonable in those with on-treatment LDL-C ≥70 mg/dL. In high-risk* patients taking a maximally tolerated statin, the addition of ezetimibe may be reasonable in those with on-treatment LDL-C ≥70 mg/dL. In very-high-risk** patients taking a maximally tolerated statin and ezetimibe, with an LDL-C ≥70 mg/dL, the addition of a PCSK9 inhibitor is reasonable.
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