The impact of very highly elevated lipoprotein(a) levels on the early onset, complexity, and extent of coronary artery disease

Introduction Coronary artery disease (CAD) remains the leading cause of death worldwide. Lipoprotein(a) [Lp(a)] has emerged as a potent, independent risk factor for stable CAD. Purpose This study aimed to evaluate the association between elevated Lp(a) and early onset, complexity and extent of CAD, as measured by invasive coronary angiography characteristics, including the synergy between PCI with taxus and cardiac surgery (SYNTAX)-1 score. Methods Lp(a) levels were assessed in 12,437 individuals who underwent lipid profiling between October 2018 and October 2019 at a tertiary. We included 558 individuals with very highly elevated Lp(a) (>230 nmol/L), who were 3:1 matched by age and sex to 223 controls with low Lp(a) (≤7 nmol/L). Kaplan-Meier survival analysis was performed to assess event-free survival for detected obstructive CAD, with age as the timescale. Odds ratios (ORs) for triple vessel disease and SYNTAX-1 score were computed using multivariable logistic regression with adjustments for clinical risk factors (age, sex, hypertension, and diabetes). Results Mean age was 57 ± 16 years and 57.4% were male. Kaplan-Meier analysis indicated that individuals with very high Lp(a) levels had a significant lower event-free survival time for detected obstructive CAD (see Figure 1). Very high Lp(a) levels were significantly associated with triple vessel disease (OR: 2.968, 95% CI: 1.122–7.851, p = 0.028). Finally, we observed a trend towards increased reclassification to an intermediate-to-high SYNTAX-1 score in those individuals with very high Lp(a) (OR: 3.619, 95% CI: 0.973–13.469, p = 0.055). Conclusion Patients with very high Lp(a) (>230 nmol/L) have shorter CAD-free survival and an increased prevalence of triple vessel disease on invasive coronary angiography. These findings highlight the importance of early Lp(a) measurement with subsequent anatomical testing in those individuals with highly elevated Lp(a), followed by intensive medical management of other risk factors.