Use of evolocumab in refractory coronary artery disease with elevated lipoprotein(a): a case report

Elevated lipoprotein(a) [Lp(a)] is a well-known yet often underrecognized risk factor for atherosclerotic cardiovascular disease and recurrent coronary events. Here, we present the case of a 71-year-old man with multiple cardiovascular comorbidities, including type 2 diabetes mellitus, systemic hypertension, and established coronary artery disease (CAD), who experienced recurrent angina and non-ST elevation myocardial infarction (MI) despite prior revascularization procedures and optimal medical therapy. Coronary angiography showed significant in-stent restenosis of the left anterior descending artery following repeat percutaneous coronary intervention. Furthermore, evaluation showed significantly elevated Lp(a) levels (86.6 mg/dL), indicating a high residual risk for cardiovascular disease. As a result, treatment with evolocumab, a proprotein convertase subtilisin/kexin type 9 inhibitor, was started. After increasing to a biweekly dosing schedule, the patient experienced a sustained and notable decrease in Lp(a) levels, reaching 16.66 mg/dL after 5 years of therapy. During this follow-up, the patient remained clinically stable, with no recurrence of heart failure, angina, or MI. This case report highlights the pivotal role of elevated Lp(a) in recurrent CAD and underscores the long-term efficacy of evolocumab in achieving cardiovascular stability when conventional therapies are inadequate.