Here is an interesting case of an elevated Lpa I was asked about. This is also on my blog whose address is below. Paul

Hi Dr. Thompson,

HERE IS THE CASE AND QUESTIONS — I need your help in a case that my colleague Dr. XXX follows. He sees a 12 yo female with mild hypothyroidism secondary to Hashimoto thyroiditis treated with levothyroxine. She had mildly elevated LDL-C level of 123, mother requested to check Lp (a) due to her own history of elevated Lp(a). Patient’s level came back very high > 600 nmol/L (ref < 75) done at Quest lab, repeated and confirmed. Apo B level was added to the sample and pending. Mothers Lpa was recently 191, but in her late teens/twenties it was 38–72. Mom recently had a cerebrovascular duplex scan which showed no stenosis and calcium score done, and the score was 0. Mom was started on Pravastatin in January just for the small, cumulative risk reduction. 12 yo pt labs: LDL of 114 on l6/3/17 and 123 on 2/18/19. Tgs 67 and 116.

Qs: have you seen a level so high for Lpa > 600?
Would you do any further tests or imaging studies, especially if pt is so young?
If Apo B is elevated, would you treat with statin?
Would you do a trial of Niacin or aspirin
Do you think this family will benefit to see someone with more expertise in Lpa, if yes any recommendations?
Mom is super nervous once she heard this result and now getting her other daughter tested.

HERE ARE MY RESPONSES –

600 mg/dl is the highest Lpa level the lab reports and we do see such values not infrequently. Often in young people with unexpectedly early coronary disease. We see one like this every couple of months.
Hypothyroidism raises Lpa, so I would first ensure that her hypothyroidism is well treated. Also, sex hormones, estrogen and testosterone (Zmunda JM1, Thompson PD, Dickenson R, Bausserman LL. Testosterone decreases lipoprotein(a) in men. Am J Cardiol. 1996 Jun 1;77(14):1244–7) affect Lpa. So, some of this girl’s Lpa being so much higher than Mom’s may be being pre-menarchal, or I assume she is.

I generally treat these folks with a statin, because the risk of high Lpa dissipates with lower LDL’s so I treat the LDL aggressively. I would probably wait in this girl, however, to see where she is when she is making lots of estrogen.

Niacin does reduce Lpa, but is a tough drug because of flushing and liver side effects. We do use it. PCSK9s lower Lpa. Lipoprotein apheresis does as well and is approved as treatment for this specific problem. We have only a couple of patients on apheresis for this indication.

I think aspirin makes sense. Lpa in the young increases stroke risk so I would probably do that in this girl.

I do not know of Lpa experts but most lipid folks know the Lpa drill pretty well. I am glad to see her and the Mom as you see fit.

Paul D. Thompson, MD
Chief of Cardiology, Emeritus
Hartford Hospital
860 972 1793
Follow on twitter — @pauldthompson5
Blog — https://medium.com/@pthomps1947