PROGRESSIVE CORONARY ARTERY DISEASE, ELEVATED LP (A) REQUIRING LIPID APHERESIS

Therapeutic Area

ASCVD /CVD Risk Reduction

Case Presentation

This is a 55-year-old female with a medical history of familial hypercholesterolemia, elevated lipoprotein (a) (Lp (a)), diabetes mellitus, myocardial infarction 2020, coronary artery disease with multiple percutaneous coronary intervention and status post coronary artery bypass surgery 2022, status post coronary brachytherapy for re-stenosis 2022, re-stenosis in 2023. The patient is on Rosuvastatin 40 mg, Ezetimibe 10mg, and Evolocumab 140 mg. Due to progressive coronary disease despite good medical therapy, the patient was referred for lipid apheresis (LA).

Background

This case demonstrates the accelerated effect of atherosclerosis mitigated by Lp(a). This patient developed progressive coronary artery disease (CAD), despite a low-density lipoprotein (LDL) of 85 mg/dl. Lp(a) is associated with increased risks of CAD, stroke, thrombosis, and aortic stenosis, particularly when greater than 125 nmol/L. Lp(a) has a pro-inflammatory effect, prothrombotic effect, and pro-atherosclerotic. Structurally similar to tissue plasminogen activator, which interferes with the natural pathways of thrombolysis. Currently, LA is the only treatment indicated for elevated Lp(a) in the setting of CAD and elevated cholesterol. The 2018 Cholesterol Guidelines state Lp(a) is a cardiovascular-enhancing risk feature. Evolocumab and Inclisiran can reduce Lp(a) up to 30 % but are not indicated as treatments. The European guidelines recommend LA for patients with elevated Lp(a) levels > 60 mg/dl, and progressive atherosclerotic cardiovascular disease despite risk factors well controlled. LA can lower Lp(a) by 60 % and LDL up to 70 %.

Conclusions

LA should be regarded as a principal therapeutic option with elevated Lp(a) >125nnmol/l in patients with progressive CAD despite maximal lipid-lowering therapy, aiming to achieve an LDL < 70 mg/dl and reduce Lp(a) > 60 % to mitigate other cardiovascular risk outcomes. A 70 % risk reduction in major adverse cardiovascular events in the first year of treatment was reported by the German Lipid Apheresis Registry. Lp(a) treatment options Pelacarsen and Olpasiran will not be available in the near future. These agents may change the need to do LA. This patient with progressive CAD, multiple interventions with very high Lp(a) benefitted from LA with greater than 80 % reduction in Lp(a) levels. Rise in Lp(a) bi-weekly, will require weekly treatments.