By Dr. Robert Superko
The Problem. Heart disease is often an inherited disease. It is also a complex polygenic disease, which means that there are several inherited factors that can contribute to your risk of heart disease. But most often when someone speaks about heart disease, we think about ‘cholesterol’.
Over the past decade, there have been numerous direct to consumer TV ads, which have publicized that by ‘lowering your LDL cholesterol’; you will reduce your risk of a heart attack. What is NOT communicated in these ads is that despite all the progress with blood cholesterol reduction, there still remains a very large group of people who are at very high risk for having a heart attack even with normal or low blood cholesterol. This is not a small group of people. As we published in the medical journal Circulation in 2008, the 25% Relative Risk Reduction with statin therapy that is often communicated to patients is only a 3.4% Absolute Risk Reduction. What this means is that if 25% of the control group had a heart attack, 21.6%, or (25%-3.4%), of the group treated with the drug, also had a heart attack! This surprises some people, but it remains true in study after study.
What is important to understand from these clinical studies is that there are other important and significant contributing factors to heart attacks other than cholesterol. These factors contribute to this large group of people still suffering a heart attack despite good cholesterol levels and/or taking a cholesterol lowering medication.
One of the really important factors that explains heart attacks, despite well controlled blood cholesterol, is a particle that circulates in your blood called Lipoprotein (a) or Lp(a) – (pronounced: ell p little a). Lp(a) is inherited and NOT affected by your cholesterol.
Lp(a) has been scientifically studied for over 50 years. Although not as often mentioned as cholesterol particle, this odd-sounding particle contributes significantly to Coronary Artery Disease (CAD) risk and is independent of blood cholesterol, blood pressure, and diabetes. This means that if your blood cholesterol is totally normal, but you have high levels of Lp(a) in your blood, your risk of having a heart attack is 2 to 3 times higher than other people and it has nothing to do with traditional CAD risk factors. The famous JUPITER study has shown that even with low LDL-Cholesterol of only 54 mg/dl, people with elevated Lp(a) had a significant risk of residual heart attack. Until recently the treatment of elevated Lp(a) was limited to high dose niacin therapy and a physical device treatment known as apheresis.
Family Ties. It is true that families are the ties that bind and nowhere is that more evident, and clear, than in the Lp(a) story. Lp(a) is passed on in families in what is termed a dominant fashion. This means that if you have this problem, you inherited it from either your mother or father, and each of your brothers and sisters, and children, have a 50/50 chance of having it as well. This means it is really important to screen family members if it is discovered that one of them has elevated Lp(a).
What’s NEW? While cutting edge physicians and clinics have measured Lp(a) in their patients for many years, the general medical community has tended to walk a more conservative line and await additional research results and recommendations by well-established professional medical organizations.
In 2003, Sandra Tremulis experienced angina while on a routine run which eventually resulted in the diagnosis of elevated Lp(a) as the cause. Along with a family history of premature heart disease, this episode prompted her to create the Lipoprotein (a) Foundation dedicated to informing the public of the risk associated with elevated Lp(a).
In 2010, the European Atherosclerosis Society reviewed the scientific data and published their recommendations on who should have Lp(a) testing. They recommend five groups of people which clearly should have Lp(a) determined.
1. Patients with premature cardiovascular disease
2. Patients with very high blood cholesterol known
as Familial Hypercholesteroaemia
3. Patients with a family history of premature cardiovascular disease and/or elevated Lp(a)
4. Patients with recurrent cardiovascular disease despite statin treatment
5. Patients with elevated cardiovascular disease risk by standard risk assessment.
In 2016, the Canadian Guidelines concluded that a continuous increase in cardiovascular risk is evident in 30% of the population with Lp(a) levels > 30 mg/dl.
In 2018, the National Heart Lung and Blood Institute concluded that Lp(a) is a highly prevalent genetic risk factor for cardiovascular disease (CVD) and also calcific aortic valve disease. They recommended several areas for future research.
In 2018, the American Heart Association, the American College of Cardiology, and 10 other medical organizations updated the cholesterol guidelines and agreed that an elevation of Lp(a) is considered to be a risk-enhancing factor and contributor to premature coronary disease.
In 2019, the National Lipid Association concluded that there is overwhelming support of elevated Lp(a) levels as an independent risk factor for cardiovascular disease.
In the past 10 years the pendulum has swung in the direction of accepting elevated Lp(a) as an independent risk factor for heart disease as well as aortic valve disease. It is now acknowledged as a major contributor to coronary heart disease by all the major medical organizations that work in the heart disease field. Specific types of people who should be tested are now defined. Treatment of elevated Lp(a) has been a difficult problem in the past and was restricted to high doses of niacin and sometimes apheresis of the blood. There is now much excitement about a new genetic treatment that may lower Lp(a) by as much as 80% with an injection every 2-4 weeks. This new treatment is an antisense oligonucleotide (ASO) that has been championed by Dr. Sam Tsimikas, a cardiologist at the University of California, San Diego. If successful, this new treatment offers a whole new approach to Lp(a) reduction and reduced heart attack risk.
Know your risk. The key to preventing heart attacks is accurately knowing your complete risk so you can make lifestyle changes before a more serious condition develops. The standard testing performed as a part of your annual physical isn’t enough. The Prevé membership now includes Lp(a) as a part of the Ultimate Health Check, which all members receive annually.
A Prevé membership also includes tools to assist with your personal health management:
Community Support Groups: Connect with the MyPrevé community to reinforce the healthy lifestyle you’re cultivating with social support along your journey.
Educational Resources: Read material from our experts to continually learn more about nutrition, fitness, and lifestyle management and make the most informed choices about your health.
Lifestyle Management Tools: You can’t manage what you don’t measure. Our lifestyle management tools are integrated with smart technology to track your fitness, vitals, weight, nutrition and behavior.
Personalized Lab Result Discussions: Our lab result specialists will schedule time with you to help you make sense of what your results mean and to develop a strategy to further discuss these results and how to improve them with your physician.
Copyright 2020 Prevé Wellness, LLC.
This information is intended for educational purposes only, it is not intended to prevent, diagnose or treat disease or as a substitute for a
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