Unmasking the Silent Culprit: Lipoprotein(a) Elevation in a Previously Healthy Individual

Background/Synopsis

Lipoprotein A [(Lp(a)] has known atherogenic and thrombotic properties. We present a young patient with recurrent transient ischemic attacks (TIA) and ischemic stroke who was found to have hyperlipidemia and elevated Lp(a) levels. In patients with increased risk of atherosclerosis, screening guidelines recommend checking Lp(a) levels once. This case emphasizes the importance of obtaining Lp(a) levels in young patients with cardiovascular risk factors and appropriate medical therapy.

Objective/Purpose

Describe the importance of Lp (a) screening in young patients.

Methods

Medical record review.

Results

A 49-year-old African American male with a past medical history of anxiety and seizures presented with left sided numbness and paresthesia. Family history was remarkable for diabetes and hypertension. He was diagnosed with a TIA. His LDL-C was 214mg/dL. He was started on atorvastatin 40mg and aspirin 81mg. He continued on this regimen despite uncontrolled LDL-C. Five years later, the patient presented with visual disturbances and headache and was found to have a PCA stroke. A TTE with bubble was negative for PFO and ASD. Holter monitor was unrevealing for arrhythmia. He was started on ezetimibe 10mg and atorvastatin was increased to 80mg. 

One year later, he presented with episodic dizziness. CTA head and neck revealed a basilar TIA.  Laboratory results showed LDL-C 140mg/dL. Lp(a) was obtained as prior workup had been equivocal and was 356.7nmol/L (ref. <75nmol/L). He was started on PCSK9 therapy in addition to his other lipid lowering therapies.

Conclusions

This patient presented with stroke and was found to have an LDL-C above 200mg/dL which should have prompted aggressive medical therapy, lifestyle modifications and close follow-up. He remained on the same medications despite uncontrolled LDL-C. Elevated Lp(a) was discovered only after the patient had suffered multiple events. On average, African American patients have higher Lp(a) levels compared to Caucasian and Asian patients, however this patient's Lp(a) levels are significantly higher than what can be solely attributed to race. It is likely that obtaining Lp(a) during the first event could have changed his clinical course over the years. This case emphasizes the importance of timely Lp(a) screening and prompt intervention.