Lp(a) screening aanbevolen bij middelmatig en hoog CV risico
Lp(a) screening recommended in intermediate and high CV risk groups
The European Atherosclerosis Society Consensus Panel is recommending that patients at intermediate or high risk for cardiovascular disease (CVD) should be screened for elevated levels of lipoprotein (Lp)(a).
The panel also provides treatment recommendations for reducing elevated Lp(a), and recommends a desirable plasma Lp(a) level.
Børge Nordestgaard (University of Copenhagen, Denmark) and colleagues write in a consensus review that, following adjustments for age and gender, there is a continuous association between elevated Lp(a) levels and increased risk for CVD, with a 13-16% increase in risk per 3.5-fold increase in Lp(a).
This association is without a threshold, and does not depend on levels of low-density lipoprotein (LDL) or non-high-density lipoprotein (HDL), or on levels or presence of other CVD risk factors, they report in the European Heart Journal.
The researchers therefore recommend one-off screening for Lp(a) in patients at intermediate or high risk for CVD: those who present with premature CVD, familial hypercholesterolemia, a family history of premature CVD and/or elevated Lp(a), recurrent CVD despite statin treatment, ≥3% 10-year risk for fatal CVD (according to European guidelines), and ≥10% 10-year risk for fatal and/or nonfatal coronary heart disease (CHD; according to US guidelines).
They add that repeat screening is only needed in order to evaluate therapeutic responses in those who are receiving treatment.
A meta-analysis of randomized, controlled intervention trials led the researchers to recommend a desirable level of Lp(a) of less than 50 mg/dl.
It has previously been shown that niacin lowers Lp(a) by up to 30-40% in a dose-dependent manner, and that it exerts other beneficial effects, such as lowering Lp(a), LDL cholesterol, total cholesterol, triglycerides, and remnant cholesterol, as well as increasing HDL cholesterol levels. A dose of 1-3 g niacin every day reduced major coronary events, stroke, and any CV event by 25%, 26%, and 27%, respectively, in actively treated patients (n=2682) compared with controls (n=3934). The team suggests that a treatment level of 1-3 g of niacin every day has a good safety profile, and is likely to reduce Lp(a) to the desirable level.
However, Nordestgaard and colleagues say that there may be no need for further treatment with niacin if statin treatment reduces absolute risk for fatal CVD or fatal and/or nonfatal CHD (according to European and US guidelines) to <3% or <10%, respectively, in a person with Lp(a) of more than 50 mg/dl, but without CVD or diabetes. But for patients with any other intermediate or high risk factor for CVD, niacin may still be justified.