Lipoprotein(a), also known as Lp(a), is an important genetic factor that can increase the risk of developing atherosclerosis (hardening of the arteries) and cardiac events, like heart attacks and strokes. It’s no wonder that when a person finds out they have an elevated Lp(a) level, they become worried. They want to know what that number means and how they can lower their risk.
A quick search reveals some disheartening information. Lp(a) levels are not impacted significantly by lifestyle factors that we usually think about to lower cholesterol and triglyceride levels, like eating a whole food plant-based diet with low saturated fat, maintaining healthy weight, and exercising. Instead, Lp(a) levels are almost entirely pre-determined by one’s genetic makeup. To make matters more difficult, while there is one therapy (lipoprotein apheresis) for people who have high Lp(a) along with both familial hypercholesterolemia (FH) and cardiovascular disease, there are no medications currently available that significantly lower Lp(a). Clinical trials for treatments to lower Lp(a) are underway.
In my clinical practice, I often talk to patients about what we can do to lower risk for cardiovascular disease in the face of a mostly unchangeable Lp(a) number. I reassure my patients that they are not powerless! On the contrary there is actually a lot they can do to lower cardiovascular risk despite the elevated Lp(a).
I like to focus this conversation by talking about lifestyle. We already know that, despite our genetics, good lifestyle can protect from much of the risk for cardiovascular disease.
In a study looking at genetic risk for cardiovascular disease, those that had an ideal lifestyle despite high genetic risk were able to lower their risk by over half compared to those with poor lifestyle. I like to say we inherit two things from our family, our genes and our lifestyle, but only one of them is in our control – lifestyle.
Researchers have also looked at whether lifestyle can impact the association of Lp(a) with cardiovascular disease. In the EPIC-Norfolk study, it was found that those individuals with elevated Lp(a) who were living a more ideal lifestyle had a 67% lower risk for cardiovascular events compared to those living an unhealthy lifestyle. In another study, the ATTICA trial, it was observed that eating a healthy Mediterranean diet can be another way to mitigate the risk associated with Lp(a). In fact, in this study after diet was controlled, there was no longer an association of Lp(a) with cardiovascular disease. Furthermore, risk associated with Lp(a) was no longer present among those with normal inflammation level (high-sensitivity C-reactive protein under 2 mg/mL), which is often impacted by lifestyle factors. Controlling lifestyle factors truly can be a powerful!
Managing All Other Risk Factors
So, where does one start? A good way to think about all the healthy factors that one should try to achieve is through the American Heart Association’s Life’s Essential 8 program. Each of these factors contribute to risk for cardiovascular disease and we know that when these factors are well managed, the risk for cardiovascular disease is lower. The eight factors include:
- Controlling cholesterol
- Eating healthy
- Being physically active
- Not using tobacco products
- Getting appropriate sleep
- Maintaining healthy weight
- Maintaining healthy blood sugar
- Having a healthy blood pressure
Lastly, what about current medications, isn’t there something that can help? The answer is yes, we know that treating high cholesterol with statins can help decrease risk of cardiovascular disease.
In one study, when LDL was lowered to a greater degree, the risk associated with Lp(a) decreased. It has also been observed that medications like PCSK9 inhibitors can lower risk for cardiovascular disease among high risk individuals. One can also talk to their physician about use of aspirin to lower risk in the setting of elevated Lp(a). My thought is that, while we wait for lipoprotein(a) specific therapies, it is best to achieve ideal lifestyle and use the therapies that have been proven to lower the risk for cardiovascular disease.
If you need help identifying the best way for you to manage your high Lp(a) and additional risk factors, the Family Heart Foundation Care Navigators are always available to help.
Author: Eric J. Brandt, MD, MHS, FACC
Affiliations: Institute for Healthcare Policy and Innovation and Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI