Cardiologist discusses Lp(a), the CVD risk factor responsible for many surprise heart attacks
Interest in lipoprotein(a), or Lp(a), is on the rise thanks to mounting evidence that the genetically inherited lipid particle may be a key missing link in unexplained heart attacks and strokes. While current treatments are limited, experts say that will likely change in the near future when new drugs begin to enter the market.
Nathaniel Lebowitz, MD, who leads preventive cardiology at Hackensack University Medical Center and serves as an assistant professor of internal medicine at Hackensack Meridian School of Medicine, has spent two decades studying this biomarker. He is now part of the American Heart Association (AHA) Lp(a) Discovery Project, a national initiative aimed at expanding physician and patient awareness as new therapies move closer to market. Lebowitz spoke with Cardiovascular Business at length about this important topic.
“Lp(a) is a major, major killer. And most of the population, and even most doctors, don't know the exact degree of how dangerous it really is,” he explained.
Lebowitz noted that Lp(a) is often responsible when patients suffer cardiovascular events despite not showing any of the normal warning signs.
“When somebody who you wouldn't expect to have a stroke or a heart attack has one and does not have traditional risk factors to speak of, check Lp(a), because it will be positive,” he said.
Lp(a) is genetic and present in about 20% of the general population. Guidelines from the AHA, American College of Cardiology and National Lipid Association now emphasize screening in individuals with a family history of premature heart disease, as well as cascade screening of first-degree relatives when Lp(a) is identified. Levels typically do not fluctuate significantly, so testing once is believed to be generally sufficient.
“I consider it a risk elevator. It's a risk multiplier,” Lebowitz said. “So if somebody is considered low risk for cardiovascular disease, but they have Lp(a) now, I would consider them intermediate risk. If they're intermediate risk, but they have Lp(a), I would now consider them high risk and treatment should ensue accordingly.”
Currently, there are no approved therapies specifically targeting Lp(a), but that may soon change. Several investigational agents are in late-stage clinical trials, including small interfering RNA (siRNA) therapies designed to silence the gene responsible for producing Lp(a).
“A siRNA will stop only that one gene that produces the Lp(a) from ever working. It'll block the contractor, the RNA, from reading the blueprint and creating Lp(a) in the first place,” Lebowitz said, describing the mechanism as “very futuristic and very exciting.”
Until those therapies become available, he said clinicians must focus on managing other risk factors.
“We can't just sit by and let our patients be at significant risk from Lp(a), so we go to plan B, which is to treat the rest of their risk factors, especially their lipids, their cholesterol, very, very aggressively,” Lebowitz explained.
Through the AHA Lp(a) Discovery Project, Hackensack is one of 10 participating institutions working to standardize workflows, expand testing and share best practices. The group meets regularly to refine quality improvement strategies and educational outreach to both patients and doctors.
Lebowitz believes that once targeted therapies are approved, public awareness will accelerate dramatically.
"You're probably going to be hearing a lot more about this in the press, on TV, in commercials,” he said. “It's much more prevalent than anybody ever realized and much more dangerous that anybody ever realized.”
Dave Fornell has covered healthcare for more than 17 years, with a focus in cardiology and radiology. Fornell is a 5-time winner of a Jesse H. Neal Award, the most prestigious editorial honors in the field of specialized journalism. The wins included best technical content, best use of social media and best COVID-19 coverage. Fornell was also a three-time Neal finalist for best range of work by a single author. He produces more than 100 editorial videos each year, most of them interviews with key opinion leaders in medicine. He also writes technical articles, covers key trends, conducts video hospital site visits, and is very involved with social media. E-mail: [email protected]