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Lipoprotein(a) -Treating the Untreatable

It's important to know your numbers

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Do you know your cholesterol numbers? There goes September … and there goes National Cholesterol Education Month. National Cholesterol Education Month is a reminder that we should all get our cholesterol checked and treat high numbers.  There are still some outstanding resources out there that can tell you everything you need to know about cholesterol. (Hint: Cholesterol is a fatty substance in your blood and a major risk factor for cardiovascular disease when there’s too much of it.)

Which reminds us, Stanley Hazen MD, PhD, recently did a web chat where a particular protein related to “bad” cholesterol was discussed. Dr. Hazen is chair of Preventive Cardiology at Cleveland Clinic. The protein he talked about is called lipoprotein(a) or Lp(a) for short. Lp(a) is one of the things your doctor is likely to test for to see if you are at risk of heart disease. The question was: Should high Lp(a) be treated. Dr. Hazen’s response was an emphatic “yes.”

But there’s one big problem. Lp(a) is not really “treatable” in the usual sense of the word. “Lp(a) is in large part genetically wired and doesn’t change very much,” says Dr. Hazen. You can, however, mitigate the danger of a high Lp(a) by going after some other risk factors for cardiac disease. Your classic LDL cholesterol, for instance.

Lowering your LDL levels also lowers level of risk caused by high Lp(a). That’s because Lp(a) is carried on the LDL particle, and does its damage in the blood stream bound to LDL. The less LDL there is to bind to, the lower the risk. “When I see high levels of Lp(a) in a patient, I set even stricter LDL goals,” says Dr. Hazen. “In fact, in a recent study of 5,000 patients that came through our Preventive Cardiology Clinic, we noted that overall mortality was increased in patients with higher Lp(a), but that if we could lower their LDL by a certain amount, the incremental increase in mortality due to the Lp(a) was negligible.”

While niacin  has been shown to be slightly effective in lowering Lp(a), Dr. Hazen wouldn’t prescribe it for Lp(a) alone. He prefers to go after LDL with statins as the first line agent. “The data for reduction in cardiac events is strongest in statin therapy,” he notes.

A patient with high Lp(a) also sets off Dr. Hazen’s stroke risk alarm. To prevent stroke, he’ll monitor the patient’s blood pressure levels more closely and more ready to prescribe a low-dose aspirin as a routine stroke preventative (unless there’s a prior history of gastric bleeding or intolerance to aspirin).

Dr. Hazen would like to see Lp(a) levels included in national guidelines for assessing cardiac risk – especially since his own research has helped demonstrate that Lp(a) is both a marker and genetic mediator of increased cardiac risk. National guidelines in some other countries are well ahead of the U.S. in this regard.

By the way – even though September has come and gone – it is not too late to get your cholesterol checked!

Tags: cholesterol, heart health, prevention, risk factors
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  • don

    My LPa level has steadily increased to 120; that right, insanely high. Therefore, I asked my Internist to swtich my to Lipitor from Pravacol; 40mg per day. Should I treat it more agressively? My total colesterol is approx. 160 with LDL around 65. Niacin is negligible and I’m not sure about a testosterone treatment. Help.

    • hearteditor

      Here is a summary from the experts from our Preventive Cardiology Clinic:
      First of all, Depending on the assay the Lp(a) value can change. Therefore, Dr. Cho states it is not that your Lp(a) has actually gone up but the assay to measure has changed.

      Dr. Frid states, “Aggressive LDL lowering with a statin is the currently recommended treatment. If LDL goal is not attained then consider the addition of niacin to reach LDL goal. We would need to know your entire CV risk profile to know what your specific LDL goal would be, but <70 is a good goal and it appears you are there.

      Dr. Cho adds, “ An LDL less than 70 is what we recommend for patients with elevated Lp(a) as well as 81mg of ASA a day; Niacin lowers it by 30%; and Testosterone is not recommended and not effective

      We would be happy to see you in our Preventive Cardiology Clinic to more fully examine your global cardiovascular risks. And see if any changes are recommended to your current regimen.

    • The_Beating_Edge_Team

      Here is a summary from the experts from our Preventive Cardiology Clinic:
      First of all, Depending on the assay the Lp(a) value can change. Therefore, Dr. Cho states it is not that your Lp(a) has actually gone up but the assay to measure has changed.
      Dr. Frid states, “Aggressive LDL lowering with a statin is the currently recommended treatment. If LDL goal is not attained then consider the addition of niacin to reach LDL goal. We would need to know your entire CV risk profile to know what your specific LDL goal would be, but <70 is a good goal and it appears you are there.
      Dr. Cho adds, “ An LDL less than 70 is what we recommend for patients with elevated Lp(a) as well as 81mg of enteric coated aspirin, provided there is no contraindication to aspirin use (GI issues, allergy, history of GI bleeding, etc) ; Niacin lowers Lp(a) by 30%; and Testosterone is not recommended and not effective
      Dr. Hazen also suggests, “Have family members get screened for not just lipid profile, but LPa as well. LPa elevations run in families; and are associated with increased atherosclerotic cardiovascular disease risks; as well as increased thrombotic risks (heart attack, stroke).
      Lastly, I recommend stop checking LPa. We don't have drugs that target LPa lowering well. And LPa doesn't change more than 10-20% over a lifetime. So we use it to set (or not) more aggressive LDLc and global preventive goals. And then don't look back. The above recommendations are based on our expert opinion. I want to make sure you understand that elevated LPa Is not yet recognized as a risk by current national guidelines in the USA (as opposed to Canada and Europe).”
      We would be happy to see you in our Preventive Cardiology Clinic to more fully examine your global cardiovascular risks. And see if any changes are recommended to your current regimen. Preventive Cardiology: http://my.clevelandclinic.org/heart/departments-centers/preventive-cardiology-rehabilitation.aspx

  • Gail

    I am a 57 year old female weighing 112 pounds at 5’3″. My lipid profile is: HDL=55, LDL=118,lipoprotein (a)=162. I was prescribed Pravastatin and took it for 6 months until severe leg cramps caused my Dr. to change to Crestor, which caused the same leg cramps. I am now on 2,000 mg of fish oil and 1 teaspoon of Metamucil daily to try a natural approach to lowering my cholesterol. However, the above numbers are from my most recent lab work. I am concerned about the lp(a). It was 24 before the Pravastatin and then 168 three months into taking the statin. After 3 months on the fish oil, it is 162, virtually unchanged.

    I have also had an A1C of 6.2, which I was recently able to decrease to 5.7 with diet and exercise. I added a rice protein powder to my diet that is meant to stabilize glucose and cholesterol levels. I eat walnuts, almonds, and pecans daily. Oatmeal increases my glucose level, so I had to remove it from my diet. I work out daily and maintain my weight.

    My paternal grandfather died at the age of 58 of a heart attack. My father has had high cholesterol, which was controlled by diet and exercise, but he now has peripheral artery disease in his leg.

    Because I do not respond well to statins, what would be the best approach for lowering my cholesterol? I see my cardiologist next month, and I am concerned about trying another statin. I worry about the possible link between statins and type-2 diabetes and ALS. I have a friend who took Crestor for years and is now dying of ALS.

    Any thoughts/suggestions would be appreciated.

    • The_Beating_Edge_Team

      Dear Gail – your timing of this question could not be better because next Tuesday – Dr. Hazen is hosting a free live health chat. You can register and start asking questions Monday after 1 pm. They will be answered the following day at noon EST. Sounds like you have some great questions for Dr. Hazen! You can find more information at http://bit.ly/IiyTGg

  • Leigh

    I’m 29 and slightly overweight (as in only 10 lbs or so) I just recently found out my Lipoprotein (a) is 160 and have tested positive for lupus anticoagulant staclot. We only found this out due to complications with my infant son. I regularly workout and make a habit to eat well.

    My hematologist seems concerned but has yet to offer any advice other than a baby aspirin a day and I’m not due to see him for another month and a half. What can I do to try and regulate my Lipoprotein (a)? I would hate to go on station therapy.

    I feel like I am a walking heart attack waiting to happen.

  • Samantha Altoids

    LP(a) produced by liver and destroyed in kidneys. Kidneys disease must not be overlooked. All 100 year olds have elevated LP(a). Elevated LP(a) slows oxidation and therefore aging. Possibly prevents cancer.LP(a) role is not known or understood, It is a mysterious thing.

  • Samantha Altoids

    Have PLAC test done if you are concerned or worried.