Low Lp(a), High LDL

Medical Q&A [Moderated]
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Greetings Gentlemen:

I’ve been following you guys for years and especially appreciate the lengthy attention to CVD risk.

I am a 54yo male with familial hypercholesterolemia (i.e. total chol. would be in the high 300’s if not controlled with statins. 40mg Crestor and 10mg Zetia bring my numbers down to normal reference ranges (barely) with LDL at 97 (working to get those numbers better through dialing in diet and exercise/quit drinking). Anyway, my cardiologist at one point a year or two ago tested my Lp(a) and it was 22 nmol/L, which I believe is quite low. My cardiologist thought that was good, but was vague on what it might mean for me.

One more piece of context: the high cholesterol is from my dads side of the family but everyone, including my father, lived to be 90-ish. His brother had extraordinarily high cholesterol in the 700’s and was only on some pre-statin 70’s treatment (I can’t recall). He lived to be about 90 in pretty good health otherwise. Their other brother, who didn’t get the high cholesterol for some reason, is now 102 years old. No heart attacks in the family history that I know of.

So, my question is what a low Lp(a) means in the context of high genetic chol.? To be clear, I’m not looking to get off my statins which are well tolerated. I’m just intellectually curious if there is any research, or even speculation on what this combination of low Lp(a)/High LDL might mean. Everything I find makes the opposite point–that a low LDL with a high Lp(a) is independently problematic. Could the low Lp(a) be protective in some way?

I would be interested in your thoughts. Thanks for your time, as always.

JDB

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So, my question is what a low Lp(a) means in the context of high genetic chol.? To be clear, I’m not looking to get off my statins which are well tolerated. I’m just intellectually curious if there is any research, or even speculation on what this combination of low Lp(a)/High LDL might mean. Everything I find makes the opposite point–that a low LDL with a high Lp(a) is independently problematic. Could the low Lp(a) be protective in some way?

I wouldn’t say that it “means” much, as it is an independent and predominantly genetically-determined risk factor.

LDL-c measures typically “include” the Lp(a) fraction, as it is an LDL-like particle. As a result, when patients have high LDL-c but have an inadequate lowering response to statins, one potential cause is high Lp(a) levels (since these aren’t lowered by statins). In your case, it would seem instead that your elevation of LDL-c is not related to Lp(a) at all.

It’s great that your Lp(a) levels are low at baseline, and especially that they remain low while taking a statin. This means that in your situation, Lp(a) is not a major contributor to CVD risk. Your family history is interesting, as it suggests your family has some other protective factor against the development of significant CVD despite the FH levels. It could be worth considering coronary artery calcium evaluation to guide future management.
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