Use of Lipoprotein(a) in Clinical Practice

Publication Date: May 1, 2019

Recommendations

I. Laboratory measurement of lipoprotein(a)

1. For the measurement of Lp(a), it is recommended that an immunochemical assay that is calibrated against the WHO/IFCCLM secondary reference material should be used and reported in nmol/L.

(I, B-NR)
573

2. When using values of Lp(a) for clinical risk assessment and treatment decisions, the use of a factor to convert Lp(a) values from mg/dL to nmol/L is not recommended.

(III - No Benefit, C-EO)
573

3. When Lp(a) values are used for ASCVD risk assessment in Caucasian patients, it is reasonable to use measured values ≥50 mg/dL or ≥100 nmol/L as levels suggesting increased risk.

(IIa, B-R)
573

II. Lipoprotein(a) testing in clinical practice

1. Adults (aged ≥20 y)

a. Measurement of Lp(a) is reasonable to refine risk assessment for ASCVD events in:

1) Individuals with a family history of first-degree relatives with premature ASCVD (<55 y of age in men; <65 y of age in women).

(IIa, C-LD)
573

2) Individuals with premature ASCVD (males aged <55 y and females aged <65 y), particularly in the absence of traditional risk factors.

(IIa, B-NR)
573

3) Individuals with primary severe hypercholesterolemia (LDL ≥190 mg/dL) or suspected FH.

(IIa, B-NR)
573

4) Individuals at very high** risk of ASCVD to better define those who are more likely to benefit from PCSK9 inhibitor therapy.

(IIa, B-NR)
573
b. Measurement of Lp(a) may be reasonable with:

1) Intermediate (7.5%–19.9%) 10-y ASCVD risk when the decision to use a statin is uncertain, to improve risk stratification in primary prevention.

(IIa, B-NR)
573

2) Borderline (5%–7.4%) 10-y ASCVD risk when the decision to use a statin is uncertain, to improve risk stratification in primary prevention.

(IIb, B-NR)
573

3) Less-than-anticipated LDL-C lowering, despite good adherence to therapy.

(IIb, C-LD)
573

4) A family history of elevated Lp(a).

(IIb, C-LD)
573

5) Calcific valvular aortic stenosis.

(IIb, C-LD)
573

6) Recurrent or progressive ASCVD, despite optimal lipid-lowering therapy.

(IIb, C-LD)
573

2. Youth (aged <20 y)

a. Measurement of Lp(a) may be reasonable with:

1) Clinically suspected or genetically confirmed FH.

(IIb, C-LD)
573

2) A family history of first-degree relatives with premature ASCVD (<55 y of age in men, <65 y of age women).

(IIb, C-LD)
573

3) An unknown cause of ischemic stroke.

(IIb, C-LD)
573

4) A parent or sibling found to have an elevated Lp(a).

(IIb, C-LD)
573

III. Treatment

1. In adults aged 40-75 y with a 10-y ASCVD risk of 7.5%–19.9%, the finding of an Lp(a) ≥50 mg/dL or ≥100 nmol/L is reasonable to be used as a risk-enhancing factor to favor initiation of a moderate- or high-intensity statin in those with on-treatment LDL-C ≥70 mg/dL (or non–HDL-C ≥100 mg/dL).

(IIa, B-NR)
573

2. In high-risk* or very-high-risk** patients, with Lp(a) ≥50 mg/dL or ≥100 nmol/L, it is reasonable to consider more intensive LDL-C lowering to achieve greater ASCVD risk reduction.

(IIa, A)
573

3. In very-high-risk** patients, taking a maximally tolerated statin with Lp(a) ≥50 mg/dL or ≥100 nmol/L, the addition of ezetimibe is reasonable in those with on-treatment LDL-C ≥70 mg/dL (or non–HDL-C ≥100 mg/dL).

(IIa, B-R)
573

4. In high-risk* patients taking a maximally tolerated statin, with Lp(a) ≥50 mg/dL or ≥100 nmol/L, the addition of ezetimibe may be reasonable in those with on-treatment LDL-C ≥70 mg/dL (or non–HDL-C ≥100 mg/dL).

(IIb, B-R)
573

5. In very-high-risk** patients taking a maximally tolerated statin and ezetimibe, with an LDL-C ≥70 mg/dL (or non–HDL-C ≥100 mg/dL) and an Lp(a) of ≥50 mg/dL or ≥100 nmol/L, the addition of a PCSK9 inhibitor is reasonable.

(IIa, B-R)
573

6. Niacin, which lowers Lp(a) concentration, is not recommended to reduce ASCVD risk in patients receiving moderate- to high-intensity statins 1/2 ezetimibe and an on-treatment LDL-C <80 mg/dL.

(III - Harm, A)
573

7. HRT with estrogen and progesterone, which lowers Lp(a) concentration, is not recommended in perimenopausal/postmenopausal women to reduce ASCVD risk.

(III - Harm, B-R)
573

* High risk 5 Individuals with clinical ASCVD including those with MI, ACS, stable or unstable angina, coronary or other arterial revascularization, stroke, transient ischemic attack, or peripheral artery disease including aortic aneurysm, all of atherosclerotic origin.
** Very high risk 5 Individuals with a history of multiple major ASCVD events or 1 major ASCVD event and multiple high-risk conditions.
The NLA grading system adopted the methodology and classification system used in the 2015 ACC/AHA Clinical Practice Guideline Recommendation
Classification System.4 All recommendations were graded by the Class (or strength) of the Recommendation and by the Levels (or quality) of the Evidence
supporting the Recommendation.

Recommendation Grading

Disclaimer

Overview

Title

Use of Lipoprotein(a) in Clinical Practice

Authoring Organization

Publication Month/Year

May 1, 2019

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

It reviewed an array of evidence-based considerations for testing of Lp(a) in clinical practice and the utilization of Lp(a) levels to inform treatment strategies in primary and secondary prevention.

Target Patient Population

Patients with risk of atherosclerotic cardiovascular disease

Inclusion Criteria

Female, Male, Adolescent, Adult, Older adult

Health Care Settings

Ambulatory, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Assessment and screening, Prevention, Management

Diseases/Conditions (MeSH)

D050171 - Dyslipidemias, D020521 - Stroke, D009203 - Myocardial Infarction, D008074 - Lipoproteins, D011322 - Primary Prevention, D055502 - Secondary Prevention, D017270 - Lipoprotein(a)

Keywords

dyslipidemia, lipoprotein(a), lipoprotein