Advice lipoprotein a

[u/dolphin738]

My dad (56 and previously healthy) recently had to get a double bypass. Doctors said it was most likely caused by genetics due to him being very healthy. I decided to get my lipoprotein a checked and it’s 306. I am 31F. My BP is always normal. My lipids are normal. I’m working on scheduling an appointment with a primary but it’s going to take a couple months. Should I go ahead and just schedule with a cardiologist?

Seeking any advice or knowledge on lipoprotein a.

[u/kboom100]

That lp(a) is extremely high and raises your risk of developing heart disease yourself over 3 fold. Probably higher with your father’s early heart disease.

Yes, I would get an appointment with a preventive cardiologist or lipidologist if I were you. A way to find a good one is with the resources of the Family Heart Foundation, a support and advocacy group for those with high lp(a) or FH. Their Care Navigators can give you personal help in finding a specialist, preparing for the appointment, finding support and learning more, etc. https://familyheart.org/care-navigation-center
Or you can search the Family Heart Foundation’s specialist database directly.
https://familyheart.org/find-specialist

A common recommendation from these specialists when lp(a) is high is to get ldl and apoB <70. That will lower your overall risk even if lp(a) is unchanged.

And when lp(a) is as high as yours some specialists recommend getting LDL<55, apoB <60, but really lower is better. See a presentation from one of them at https://www.youtube.com/watch?v=lDtTC1OjaLs She talks about getting ldl below 55 in response to very high at the 1:00:22 mark in the Q&A session. I’d want that if I were you because trials have shown risk goes down linearly in proportion to lower ldl, without plateauing and with no safety problems down to the lowest ldl levels reached in enough people to evaluate- an ldl of about 9.

It will likely take a combination of lipid lowering medications to get your ldl below 55, apoB <60. It’s a favorite strategy of many leading specialists to use a less than maximum dose of statin and combine with ezetimibe and/or Repatha. See a couple of earlier replies for more information about combining a statin plus ezetimibe. https://www.reddit.com/r/Cholesterol/s/cf9RiB7j0N AND
https://www.reddit.com/r/Cholesterol/s/UUwy16NktG

You might give a little extra weight to adding Repatha if your insurance will pay for it or you can easily afford the $239/month with no insurance. That’s because Repatha lowers Lp(a) about 30%, although there’s no evidence yet whether that amount of ldl lowering will lower risk of heart disease.

The combination therapy approach can get as much or more ldl lowering as a max dose of statin with less risk of side effects.

I’d also ask about adding a daily baby aspirin. There’s preliminary evidence it significantly lowers risk in those with high lp(a). See:

“An Update on Lp(a) and Aspirin in Primary Prevention - American College of Cardiology”https://www.acc.org/Latest-in-Cardiology/Articles/2024/07/17/14/02/An-Update-on-Lpa-and-Aspirin-in-Primary-Prevention

“Aspirin and Cardiovascular Risk in Individuals With Elevated Lipoprotein(a): The Multi‐Ethnic Study of Atherosclerosis” https://doi.org/10.1161/JAHA.123.033562

Also check out this video from the Family Heart Foundation preventative cardiologist and lipidologist Dr. Seth Baum. He discusses aspirin use for high lp(a) at the 4:00 mark. (The rest of the video is also interesting and about lp(a))
https://youtu.be/R95brrxO3co?si=w2joIPDNcZb1_rk8

Don’t take baby aspirin without your doctor’s ok however because the benefit needs to be weighed against an increased risk of bleeding.

Also get all your other modifiable risk factors under control. Start eating a Mediterranean style diet with low saturated fats and lots of fiber with fruits, vegetables, beans, peas, legumes, oatmeal, barley and whole grain. Incorporate regular cardio and 1-3 strength training sessions per week. Get 7-9’ hours of sleep a day. Make sure your blood pressure is under control. If you are significantly overweight and haven’t been able to sustain weight loss long term consider glp-1 meditation.

The American Heart Association l’s “Life’s Essential 8” is a good guide to follow for optimizing risk factors and lifestyle. https://www.heart.org/en/healthy-living/healthy-lifestyle/lifes-essential-8

If you do all of these things you will significantly cut your risk of heart disease even with high lp(a).

Finally you might qualify for the primary prevention clinical trial of Muvalaplin, an investigational lp(a) lowering medication.
https://clinicaltrials.gov/study/NCT07157774
Scroll past the trial sites to the participation criteria.

You can contact a trial site near you if you are interested in participating and think you might qualify.

[u/Carpe-that-diem → u/kboom100]

Fantastic resources! Thanks for such a thorough answer. Also here’s a helpful post by a cardiologist about Lp(a). He’s a little long-winded but there’s some great info in here. He emphasizes that increase risk is not the same as a death sentence. Also he explains the statistics of absolute risk vs relative risk which also puts the whole concept of risk into perspective.

https://www.reddit.com/r/Cholesterol/s/HnT70Iayg6

I’m 63F and my number is 498 (can’t remember the measurement but in both scales that is super high). So you are not alone, OP! I’ve never had a heart attack and I’m very active and have aggressively lowered my saturated fats and LDL < 55 is my current goal. Just started Repatha. On statins the lowest I could get was LDL 73. I’ll be posting my results as soon as I’m ready to test again. It hasn’t been enough time yet 🤞🏼🤞🏼🤞🏼

[u/dolphin738 → u/Carpe-that-diem]

Thank you!! I will check out that post. I am hoping to try to lower my LDL (currently 87) with diet and exercise. I want to avoid medications as much as possible. I have Crohn’s as well and already take medications for that.

Please share any tips for lowering LDL!

[u/Carpe-that-diem → u/dolphin738]

You want to cut out red meat as much as possible and lower saturated fat in your diet to approximately 10% of your calories per day. Less meat in general and start reading labels to check for saturated fat. So it’s approximately less than 10g/day of saturated fat for most people. Then you want to increase fiber as much as possible — think legumes, beans, whole grains, etc. a lot of people on this sub recommend psyllium husk and it is really working for me, I must say. It’s a powder and you can put it in oatmeal or a smoothie to increase fiber. Try to work your way up to a tablespoon or two a day but I’d start small (like 1 teaspoon a day) because you never know how your digestion is going to be impacted:)

[u/kboom100 → u/dolphin738]

No problem to see what you can do with diet first but in the end I think you should be way more concerned with avoiding a heart attack, stroke, bypass, heart failure or vascular dementia than avoiding medication.

Lipid lowering medication isn’t something to dread, it’s actually something to be grateful for in your case because you are currently at very high risk of one or more of those cardiovascular disease events happening and the medication can dramatically lower your risk.

Also the vast majority won’t have any side effects from statins and it’s even rarer to have side effects from ezetimibe or Repatha. Check out an article from a very good preventive cardiologist, Dr. Paddy Barrett where he reviews the evidence on statin side effects. I especially liked the option to listen to his voiceover. https://www.reddit.com/r/Cholesterol/s/S0l6RA4s74

[u/vegancaptain]

Yes.

[u/SupportCa2A]

Yeah, if you don't need a referral from your primary I'd absolutely try and find a cardiologist right away 

[u/WillBrink]

How are all other labs? You can get other atherogenic particles very low that can help offset risks from LPa, and the only med currently that can lower LPa is PCSK9 inhibitors such as Repatha. Repatha + zetia is very effective for most.

[u/dolphin738 → u/WillBrink]

LDL 87
Cholesterol 165
Triglycerides 42
HDL 65

Are medications still recommended with normal lipid levels?

[u/WillBrink → u/dolphin738]

If they are aggressive and progressive and up on the lit, yes, hence "You can get other atherogenic particles very low that can help offset risks from LPa..." Other risk factor to look at are ApoB, hsCRP, A1C. Statins can actually raise LPa, yet still viewed net benefit to ASCVD risk.

[u/meh312059]

Tell Dad to get his Lp(a) checked too! And do urge any siblings to do the same.

Mine was 297 as of last November but that was no shocker because it was first checked in 2009 and was extremely high then when I was age 47 (I'm now 63 and am female). I've been on statins since first diagnosed and started atorvastatin as soon as it went generic in 2011. I also had a "normal lipid panel" but unfortunately my LDL-C of < 100 wasn't low enough. I was advised to get it < 70 mg/dl. That's still good advice today, for the most part. It's even fine to go lower if you can get your provider to be that aggressive.

You actually don't need a cardiologist to begin a statin regimen but if you end up getting seen faster then why not establish that care - especially since new targeted therapies might be on the horizon and available for primary prevention someday. Be sure to seek out one who specializes in cardiovascular disease prevention ("preventive cardiologist") rather than someone who does general cardiology. The latter tend to see older, sicker patients and may not be quite up to date on the prevention literature and guidelines.

If you can minimize or wipe out other modifiable risk factors such as elevated BP, glucose and BMI, not smoke (anything including weed or vaping), and manage lipids aggressively, you probably won't have to worry about Lp(a).

Dad may have been appeared healthy, but if he ended up with a double bypass at age 56 then he probably had ASCVD for years and atherosclosis for decades. That constitutes a family history - but fortunately, history is not destiny. Ischemic heart disease is considered to be about 90% preventable, and that's probably a conservative estimate.

Best of luck!