Lipoprotein(a): Reviewing the Significance and Looking to the Future

Our commitment to comprehensive cardiovascular care has been steadfast for more than 20 years, and this includes evidence-based genetic testing. One genetic test garnering recent public attention is lipoprotein(a), an inherited lipid disorder affecting around 23% of the population. Though it is just starting to gain public attention, Lipoprotein(a) has been a known concern to researchers for more than six decades and is nothing new for Bale Doneen providers or patients. The Bale Doneen Method has recommended Lp(a) testing for more than two decades, meaning: If you have been a patient in our program, your lipoprotein(a) level has been tested; and if abnormal, it has been treated with the treatments currently available to us. 

Considering ongoing (and exciting!) direct-to-consumer marketing of new pharmaceutical treatments on the horizon, we wanted to circle back to our well-known foe to clarify misconceptions and emphasize our long-standing awareness and management of this common, but dangerous, condition. 

What is Lipoprotein(a)?

Lipoprotein(a), or Lp(a), consists of a cholesterol particle bound to a unique protein called apolipoprotein(a). This lipid compound significantly increases the risk for early and aggressive atherosclerotic disease, including coronary artery (heart) disease, and aortic valve calcification. Unlike other lipoproteins, Lp(a) is inherited from one or both parents, creating family histories littered with tales of heart attacks and strokes in young, seemingly healthy individuals. Because lipoprotein(a) is a genetic marker, if your level is within normal limits, it only needs to be tested once. Generally, a level of less than 30mg/dL or less than 75 nmol/L is considered to be in the normal range. 

The Bale Doneen Approach: Long-Standing Awareness and Proactive Treatment. 

Contrary to the misconceptions created by recent marketing campaigns, Lp(a) is far from a new discovery. Experts in the field of lipidology and preventive cardiology have long recommended Lipoprotein(a) be tested once in all adults for risk stratification — an approach supported by an abundance of scientific evidence. For example, a collection of 2009 genetic studies showed that Lp(a) elevation was a causative factor in acute coronary events, and a 2014 study showed that Lp(a) elevation enhanced cardiovascular risk and also suggested reclassification of up to 40% of previously intermediate risk individuals. In addition, the 2022 European Consensus statement on Lp(a) states that Lp(a) should be measured at least once in adults, that interpretation of Lp(a) should impact overall CVD risk category and that more intensified treatment may be warranted based on a positive result. In short, Lp(a) is not new, and it is a big deal. 

The Bale Doneen Method has thoughtfully followed the growing body of evidence that Lp(a) elevation is a major player in early, aggressive arterial disease. Studies conducted by Willeit et al. (2014, 2018) and Lange et al. (2016) underscore the significance of baseline Lp(a) levels in predicting both initial and recurrent cardiovascular events, reiterating the critical role of a proactive approach to cardiovascular disease prevention. 

Treatment: Current and Future

Currently, the only approved treatment for Lp(a) elevation is Vitamin B3, or Niacin. Niacin has been used for more than 50 years to reduce cardiovascular events and mortality and is known to lower lipoprotein(a) concentration by silencing the Apo(a) gene expression in the liver cells. The effect of Niacin is dose-dependent, leading to a 25-38% reduction in Lp(a) concentration when administered at a dose of 2-4 grams daily. Vitamin B3 has been a mainstay of treatment within The Bale Doneen Method, and we will continue to utilize this powerful tool until we have something safe and superior to offer our patients. 

Additionally, PCSK-9 inhibitors are not approved for the indication of lowering Lp(a), but evidence does suggest at least a modest lowering of this dangerous lipoprotein. 

Recent media attention and direct-to-consumer marketing has stemmed from the development of a new class of medications aimed at eliminating the increased cardiovascular risk posed by lipoprotein(a) elevation. The most recent excitement has stemmed from phase 2 results on the medication Lepodisiran. Lepodisiran is an extended duration siRNA medication that is designed to impair the mRNA coding for apolipoprotein(a). The phase 2 preliminary results are promising and exciting, showing Lp(a) reduction of 94.8% after two doses of the medication when measured at day 180 and 53.4% below baseline level at 540 days. 

At The Prevention Center, our dedication to proactive health care encompasses early identification, continual monitoring and effective management of lipoprotein(a) and related risk. We strive to always remain up to date with new advancements in treatment and are committed to ensuring our patients receive the very best comprehensive and personalized care. In short, once we have outcome and safety data from these exciting studies, you will be the first to know how this will change our treatment protocol.