Left Main Heart Stent at Age 34: The Importance of Lipoprotein(a)

In medical school nearly 40 years ago I was taught that heart disease is mainly due to smoking, hypertension, diabetes, cholesterol disorders, and a family history of early heart events (Framingham risk factors). Most patients are still evaluated by obtaining information regarding these 5 factors. Missing from this approach are major advances in understanding the development of coronary artery disease (CAD). One of the most important advances is the recognition that a type of lipid (cholesterol) particle that is inherited on a genetic basis is both common and causes a large number of tragic cardiac events, even deaths. This particle is called Lipoprotein(a) or Lp(a) and can be easily measured in a blood sample at most laboratories. A recent case at the Kahn Center for Cardiac Longevity was striking for the role of Lp(a) in causing early and severe CAD.

Case Study

In 2009, a 34-year old man with no known cardiac disease began training for a half-marathon running event. He had no known heart disease, never smoked, was on no medications, and did not have a history of premature CAD. He developed jaw pain while training and scheduled a medical evaluation leading to a stress test. Due to abnormalities found on the treadmill test, he had a coronary angiogram showing a severe narrowing in his left main coronary artery (LMCA), the largest artery to the heart. After various opinions, he was treated with a single coronary stent. He had complete resolution of his exertional jaw pain and has never required additional invasive procedures or hospitalizations. He was maintained on cholesterol lowering therapy after his procedure along with aspirin.

When seen at my clinic in 2020, he brought older laboratory testing that identified that his Lp(a) level in 2014 was severely elevated at 431 nmol/L, with a normal of <75 nmol/L. In 2019 his total cholesterol was 152 mg/dl, HDL 35, LDL 85 and triglycerides were 153. He never had been diagnosed with hypertension or diabetes. He was maintained on rosuvastatin 20 mg, ezetimibe 10 mg, fenofibrate 140 mg, aspirin 81 mg, and clopidogrel 75 mg daily since his stent.

A recent laboratory evaluation in 2020 revealed a HgbA1C of 5.3%, normal liver and thyroid studies, a total cholesterol of 132 mg/dl…