Lipoprotein(a) and Heart Health: The Importance of This Inherited Cholesterol-Related Protein

Physicians and medical researchers are increasingly recognizing the importance of a third type of cholesterol known as lipoprotein(a) – or Lp(a). What exactly is Lp(a)? Most importantly, should you get your levels of Lp(a) tested?

Lp(a) is a lipoprotein -- meaning it is made up of fat and protein -- that affects how your body handles lipids, or fat, in the body that is similar in structure to low-density lipoprotein (LDL) cholesterol, or what many refer to as the “bad cholesterol” -- which is really the particle that carries cholesterol into the arteries.

Like LDL cholesterol, Lp(a) deposits cholesterol in the arteries and can show up in plaque. It’s also found in cells that line small blood vessels and in tissues where normal regeneration and healing occur.

Lp(a) is genetically inherited, and in high levels is a common independent risk factor for heart disease. If your parents, grandparents, or other relatives developed heart disease at a young age or if you have heart disease and it’s been hard to manage, it’s important to include Lp(a) in discussions with your doctor.

Jonathan Fialkow, M.D., Chief Population Health Officer for Baptist Health and chief of cardiology at Baptist Health Miami Cardiac & Vascular Institute.

Lp(a) is different than LDL in that even if a person living a healthy lifestyle, including a well-balanced diet and regular exercise, he or she may still have high levels of Lp(a). In contrast, diet, exercise and weight management can substantially help lower LDL levels and raise high-density lipoprotein (HDL), also known as the “good cholesterol.” A healthy lifestyle, sometimes combined with medications like statins, can help people regulate their good and bad cholesterol levels.

Lp(a) Treatment, Monitoring by Lipid Specialists

Cardiovascular specialists with the Lipid Management Program at Baptist Health Miami Cardiac & Vascular Institute work together to assess an individual’s risk of Coronary artery disease and monitor a patient’s lipid levels routinely, referring primarily to cholesterol and triglyceride levels. They coordinate individualized treatments with nutritionists, exercise physiologists, genetic counselors and other specialists, explains cardiologist Jonathan Fialkow, M.D., chief medical executive of Population Health, Value and Primary Care for Baptist Health, and deputy director of Clinical Cardiology at Baptist Health Miami Cardiac & Vascular Institute.

Lp(a) treatment and monitoring are also part of the Institute’s Lipid Program. And it’s increasingly a part of the Institute’s Cardiometabolic Clinic. The Institute’s team of advanced lipid and prevention cardiology specialists “have long recognized the importance of Lp(a) evaluation and its implications in cardiovascular disease,” said Dr. Fialkow. It is part of the evaluation of every patient.

“Lp(a) is a protein that is genetically coded (not very responsive to diet and lifestyle) that effects one’s LDL-cholesterol particle and increases risk for cardiovascular disease,” explains Dr. Fialkow. “Like with other risk factors, a person’s Lp(a) level will determine how aggressively one should improve their risk factors and how intensely to receive cardiovascular prevention strategies.”

Testing for Lp(a) Can Be Challenging

Measuring Lp(a) can be more challenging than testing for routine cholesterol levels. About 20 to 30 percent of people worldwide are estimated to have elevated levels of Lp(a), which are generally thought to start between 30-50 mg/dL, according to the National Institutes of Health (NIH).

“There are different measurements for Lp(a), so one should make sure they are looking at the right things,” said Dr. Fialkow. “When measured in mg/dl, 30-50 is borderline high, and over 50 is high. This does not necessarily mean one has heart disease. It just may place them at a higher risk of developing coronary artery disease/atherosclerosis.”

Lp(a) is not currently part of a routine blood analysis by the medical community many European and American organizations now recommend the test to be done once in every adult as part of preventive screening

“It is not part of a regular evaluation or lipid panel currently,” explains Dr. Fialkow. “It should be checked at some point in all adults. Lp(a) is currently not a target for therapies, rather it changes our targets for other therapies. For example, we may set a goal for LDL-cholesterol levels lower if Lp(a) is high in an individual.”

High Lp(a) Levels Can Be Riskier Than High LDL Levels

An important aspect about Lp(a) is that high levels of this genetically coded condition can be more dangerous than the standard high LDL levels that most people are familiar with.

“Lp(a) is an apoprotein -- a protein that effects lipoproteins which are the carriers of cholesterol and triglycerides and impart risk to our cardiovascular system,” explains Dr. Fialkow. “When it attaches to the lipoprotein, that combined molecule appears to have certain features making it stickier to the arteries and more oxidized (inflammatory ) -- and thus more likely to cause artery damage and disease. Think of two people with the same age and same lipid levels. The one with the high Lp(a) may have more extensive disease in their arteries.”

Not all patients with high Lp(a) levels have cardiovascular disease, so lipid specialists at the Institute appropriately identify those who would benefit from a higher level of preventive care than generally delivered in the community. The interpretation can be complex, so we want to avoid unnecessary fear if elevated, which it why the Institute’s lipid management program handles many patients with elevated Lp(a)

“We have a series of patients who have had recurrent heart attacks and stents, despite being on statins and other standard therapies,” said Dr. Fialkow. “And when we identify elevated Lp(a), we develop customized treatment plans and significantly decrease their risks of further procedures and cardiac events.”