Heart Attack in a Healthy 34-Year Old With Elevated Lipoprotein(a) Cholesterol

Everyone has heard about LDL cholesterol, elevated blood pressure, diabetes mellitus and smoking in terms of heart disease risk. Unfortunately, most have not heard of Lipoprotein(a), also known as Lp(a) or the “sticky” cholesterol. Lp(a) is a low-density lipoprotein (LDL) cholesterol particle with an added tail called apolipoprotein(a) that makes it a unique and potentially dangerous for future heart attack, stroke, and valvular disease. An individual’s Lp(a) level is 80–90% genetically determined in an autosomal codominant inheritance pattern with full expression by 1–2 years of age and adult-like levels achieved by approximately 5 years of age. The Lp(a) level remains stable through an individual’s lifetime regardless of lifestyle. Approximately 1 out of every 4 person inherits the gene for Lp(a) and manifests an elevated level in the blood lifelong. Although most health care practitioners are not yet routinely ordering a simple blood test to assess the presence and level of Lp(a) in their practice, my preventive cardiology clinic is a referral center for those with Lp(a) and I see many patients. This case study of a healthy 34 year old emphasizes the need to widen our testing, and improving our therapy, for Lp(a) elevations.

CASE STUDY

A 34- year old married man with no prior medical history other than use of famotidine for heartburn was playing hockey when he began to experience chest pain. He regularly played hockey without difficulty. When his symptoms persisted he was transported to a local hospital and underwent emergency cardiac catheterization. His left circumflex artery was 100% blocked and his proximal left anterior descending artery was 80% narrowed. Both were resolved with drug eluting stents at that setting. His troponin muscle enzyme was elevated but a follow-up echocardiogram a day later showed preserved heart strength. He was discharged a few days later on medical therapy including high dose atorvastatin.

He denied smoking, issues with blood pressure or blood sugar, or a family history of early heart disease in immediate family members. A maternal grandfather had died at age 37. He used no recreational drugs. His BMI was 25. He exercised at the gym or playing hockey 6 days a week. He had no snoring or apnea.