Understanding the Importance of Lipoprotein(a)
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Managing cardiovascular risk is the 11th point in the 15-point guide of our atmasvasth quest to live long healthy.
Measure your blood pressure yourself once a quarter, if normal, less or more frequently if abnormal.
Check your blood sugar and HbA1c once a year if normal, more frequently if abnormal. Motivate others around you to do the same. Start at age 30.
Check your lipid levels once a year, more frequently if abnormal.
Check your QRisk3 score yourself - if the cardiovascular risk is found high, see your doctor. If normal or low, then repeat once a year.
Also check your AHA LE8 score - along with the QRisk3 score, it gives you a sense of your health. Repeat once a year.
One ECG during an annual health check-up and definitely after the age of 65 is important, to check for atrial fibrillation.
A coronary calcium score (CAC) test may help after the age of 45, if you have intermediate risk (not too low and not too high) or QRISK3 or AHA LE8 testing.
Follow your doctor’s advice on management of high blood pressure, diabetes and high lipid levels, but do your own research on the medications and question the treatment rationale, if it seems irrational.
It is never too late to start taking care of these issues.
In one of my first articles on this subject, in Jan 2021, I had mentioned that elevated LDL-C lipid levels were the 3rd most common cause of cardiovascular disease in 2019, a rank that is unchanged as of 2022, the last year till when data is available. It was the 6th commonest cause of death as a risk factor in India in 2019 and this is still likely the case.
The logic, driven by good randomized controlled trials (RCTs) for over 35 years now is that high LDL-C levels increase the risk of cardiovascular events (stroke, heart attacks, etc) and hence lowering these levels using statins and similar newer drugs reduces cardiovascular risk, reduces the risk of heart attacks and strokes and improves healthspan and lifespan. The higher the initial, baseline cardiovascular risk, the more effective are lipid-lowering drugs.
Lipid levels are one part of overall cardiovascular risk, which also includes other factors such as family history and genetic risk, blood pressure and diabetes, food habits, smoking, sleep patterns and other similar parameters. While your doctors will assess all these parameters when you visit them, assessing risk yourself using online scores such as QRISK3, or AHA LE8 (see above) will give you a sense of where you stand and how much effort you need to put in yourself, with or without drugs, to reduce your risk, using the pillars of physical activity, sensible eating, control of blood pressure and blood sugar and drugs.
One other parameter that should be measured whenever you get your lipid levels checked next, if not already done, is lipoprotein(a) [1]. Lipoprotein (a) is also a form of lipid in the blood. High levels of lipoprotein(a) are associated with a significantly increased risk of heart attack and aortic valve disease. These levels are mainly genetically determined (90%) and unlike with other cholesterol levels that can be changed with medicines and lifestyle measures, currently there are no interventions that can reduce high lipoprotein(a) levels, though this is likely to change in the future.
A lipoprotein(a) level > 30 mg/dl is considered abnormal and one in five people in the world have levels higher than 50 mg/dl, the highest in people from Africa, moderate in people from South Asia, the Middle East and Latin America and least in South East Asia, East Asia and Europe.
The Lipid Association of India 2024 Consensus Statement [2] mentions that one lipoprotein(a) test should be done at age 18 to understand cardiovascular risk, which practically implies that the first time you get lipid levels done, or the first time you test for them after reading this, you must also test for lipoprotein(a) levels.
In short, what does this mean for you and I?
1. If you have not yet had your lipoprotein(a) levels checked till now, please do so.
2. If the reading is higher than 30 mg/dl, it adds to your cardiovascular risk. Please have a conversation with your doctor.
3. It will mean intensifying all other measures to reduce overall cardiovascular risk, which means
Physical activity - moderate to high
Sensible eating
No smoking
High-intensity statins and other similar lipid lowering drugs
Intense blood pressure and blood sugar control
Weight reduction if significantly overweight/obese
Footnotes
1. Nordestgaard BG, Langsted A. Lipoprotein(a) and cardiovascular disease. Lancet. 2024 Sep 28;404(10459):1255-1264. doi: 10.1016/S0140-6736(24)01308-4.
2. Puri R et al. Navigating Cardiovascular Risk and Lipid Management in Indian Patients: Key Messages from the Lipid Association of India 2024 Consensus Statement IV. J Assoc Physicians India. 2024 Aug;72(8):80-82. doi: 10.59556/japi.72.0614