Another lipoprotein (a) question

Medical Q&A [Moderated]
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Hey BBM team!

Just recently decided to get my lipoprotein (a) checked: 264 nmol/L. Yikers!

Other stats:

Mostly recently just got CAC score: 0. (Yay)

BMI: 27 (5’10", 187lbs), waist 32"

Meds: amlodipine 5mg, Crestor 20mg,

BP average 117/72

Total cholesterol: 144mg/dL

LDL: 77mg/dL

HDL: 42mg/dL

Triglycerides: 127mg/dL

Resistance training: 3x per week

Cardio: 250-300min (mostly zone 2); steps per day 10-15,000

Fiber (3 month average): 40g but gradually increasing

Sat fat (3 month avg) 19g but slowly lowering to below 15

Sleep: 6-8 hours

Family history (from a cardiac perspective): 1 stroke that I’m aware of on grandmother at 80+ yo and 1 stent for my dad at 70 without MI.

Other notes: that cholesterol panel was taken in the process of making some lifestyle changes. I went from around 200 to 187lbs, increased fiber (25–>40), lowered sat fat (25–>15), and increased cardio (60-90min —> 250-300) . I’m currently consuming 0 alcohol whereas I was drinking more liberally (1-2 drinks every night or other night; 8-12 drinks per week).

I’m hoping that some of those lifestyle modifications will move my cholesterol numbers in an even more positive direction. I’m happy CAC was 0 but understand that that doesn’t mean I wouldn’t benefit from continuing to optimize my cholesterol panel!

I guess my question is, with a lipoprotein (a) that elevated, when would it be reasonable to consider additional medications / increasing dose of meds? I’m leaning toward getting another cholesterol panel since having made some of these lifestyle changes before rushing to increase meds, but wouldn’t be against the med route if those changes don’t get me where I need to be. I’d like LDL to at least be below 70 but honestly as low as possible would be great lol

Overall trying not to freak out about the lipoprotein a measurement but definitely take it seriously and get all the input I can get to decrease overall risk. If a consult is more appropriate I’d be happy to do that as well. Thanks yall!

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Hey Dylan, great to hear from you and hope things are going well!

Overall it sounds like you’ve made substantial lifestyle changes that benefit your health, but I hear you on this concern regarding the Lp(a). And while certainly reassuring, as you know it’s moreso expected that you’d have the CAC of zero at your age. The family history is also reassuring here (particularly no early-onset ASCVD or aortic stenosis).

Although (for now) we typically suggest one-time Lp(a) checks, in your case since you are taking rosuvastatin 20 mg, I’d actually be curious whether you’re a bit of a “hyper-responder” in terms of Lp(a) increase while on statin therapy. For example, whether things would look better on 5-10 mg rosuvastatin + 10 mg ezetimibe, rather than the 20 mg of rosuvastatin, for both traditional lipid parameters and Lp(a) level. So this might be a scenario where I’d actually consider some tinkering and re-checks, if accessible for you.

We are expecting results from the Lp(a) Horizon CV outcomes trial later this year, which will be interesting to see – although not directly applicable to your situation, since those will all be higher-risk patients with established disease. But it could inform future decisions on how aggressive to be with Lp(a) lowering, particularly as PCSK9 inhibitors become cheaper and more accessible.

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Oh cool! I haven’t come across the hyperresponder aspect you mentioned. What’s the relationship there—between statins and lipoprotein (a)? Are you suggesting that the statin could be playing a role in elevating the lipoprotein (a)? I do know that statins have a marked effect on my lipids, nearly halving some of my numbers (although typically when I initiated a statin I undoubtedly made a few lifestyle changes in the process).

P.S. Everything is well! Just settling into the clinic life and in the process of building our first house! Definitely a busy time but finding ways to stay active and healthy.

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Yes, statins increase Lp(a) by about ~10-20% on average – meaning that some patients have less of an increase, and others more.

I’ve seen some patients have quite dramatic increases, in which case I often either trial switching to pitavastatin (again, often combined with ezetimibe) instead, or switching to a PCSK9 inhibitor if the patient is willing/able to access one.

https://academic.oup.com/eurheartj/article-abstract/41/24/2275/5492355

https://www.atherosclerosis-journal.com/article/S0021-9150(24)00363-0/fulltext

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Oh interesting! I’ll run it by my primary and see if she’s willing to do some experimenting. And then recommend re checking lipids (including little a) in…8-12 weeks?

As an aside, this Little A is proof the devil is real. Like honestly. Mostly unaffected by meds/lifestyle, independent risk factor for ASCVD, nearly purely genetic, only way to manage is by lowering risk via other channels…oh but btw one of the most effective channels we have to lower risk, ie statin, actually increases it?!

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Dylan,

One minor bit of advice to add, if you find that the 20 mg of crestor causes muscle aches talk to your doctor about lowering the dose and adding in 10 mg ezetimibe. Like you, I have elevated lp(a) - around 230. To reduce overall risk I started on 10 mg atorvastatin but it caused persistent aches in my arm to the point it effected my workouts. I dropped the dose to 5 mg atorvastatin and added 10 ezetimibe. The aches went away and my lipid numbers improved even more.