7-039 Appropriateness of Lp(a) testing in secondary care

Introduction Lipoprotein(a) Lp(a) is an established independent risk factor for atherosclerotic cardiovascular disease (ASCVD) and is increasingly assessed in secondary care. HEART-UK guidelines for Lp(a) testing, recommend testing in people with: (1) Premature coronary artery disease (CVD) or a family history of premature CVD, (2) Family history of elevated Lp(a), (3) Familial hypercholesterolemia, (4) Aortic stenosis, and (5) A borderline or less than 15% 10-year CVD risk. Furthermore, testing should be performed only once in an individual's lifetime, as Lp(a) levels remain stable over time. We sought to assess the appropriateness of Lp(a) testing in a tertiary hospital against these guidelines. Methods We implemented a quality improvement initiative to review Lp(a) testing at Barts Health, a tertiary centre in London. We captured all Lp(a) measurements made through the pathology system, and retrospectively reviewed the electronic health records (EHRs) of these patients to assess the indications for testing and the departments requesting these tests. Results Between July 2017 and April 2024, a total of 2,098 Lp(a) measurements were identified, comprising 1902 unique patients. In 120 (6.3%) patients, we could not identify either the indication or the department requesting the test, leaving 1,782 patients for final analysis. Lp(a) testing was carried out by seven departments: (1) Lipid Clinic, (2) Cardiology Inpatients, (3) Research Teams, (4) Stroke outpatient, (5) Paediatrics inpatients, (6) Metabolic Clinics, and (7) Other departments (Where departments were unidentified). The most common indication for testing was premature CVD (57.6%), followed by familial hypercholesterolemia (16.3%). However, 23% of the requests did not meet the criteria set out by HEART-UK. In terms of departmental utilisation, the Lipid Clinic performed most tests (73.8%), followed by Other Departments (17%), Cardiology Wards (4.76%), Metabolic Clinic (2.74%), Research Teams (1.40%), Stroke outpatient (0.50%), and Paediatrics inpatient (0.17%). Upon reviewing individual departments, significant variation in adherence to appropriate testing criteria was observed. Compliance rates meeting HEART-UK criteria were as follows: Lipid Clinic - 90%, Cardiology Wards - 66%, Metabolic Clinic - 59%, Other Departments - 31%, and Research Teams - 16%. Of note 106 patients had repeat testing of Lp(a). Of these 47 were for PCSK9 therapy monitoring, but there was no clear reason for repeat testing in the remaining 59. To evaluate the impact of the 2019 HEART-UK guidelines on test appropriateness, we compared testing patterns before and after 01/01/2020. Before this date, 574 tests were conducted, with 69.16% (397) meeting the criteria. Afterward, 1,215 tests were performed, with 81.49% (978) meeting the criteria. Conclusion Our quality improvement initiative identifies key areas within this hospital where clinician education is essential to improve Lp(a) testing. Despite the reduction in inappropriate testing following HEARTUK guidelines, underutilisation persists in critical services such as stroke and vascular department. Targeted education is needed to raise awareness about the test and its indications, ensuring broader, more appropriate testing that optimises both cost efficiency and patient risk identification.