PURPOSE OF REVIEW: The measurement that is termed 'LDL-cholesterol' (LDL-C) includes the cholesterol content of lipoprotein(a) [Lp(a)-C], which can contribute approximately 30-45% to measured LDL-C levels as a percentage of its mass. We review the implications of achieved very low LDL-C levels in patients treated with potent LDL-C-lowering agents in the context of varying Lp(a) levels. RECENT FINDINGS: Combination therapy with statins, ezetimibe, and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors can lower LDL-C to unprecedentedly low levels. Recent PCSK9 trials have shown that routine achievement of mean LDL-C less than 50 mg/dl is feasible, along with the modest reductions in Lp(a). Many patients will achieve LDL-C less than 25 mg/dl with concomitantly elevated Lp(a) levels that contribute substantially to the measured 'LDL-C'. Therefore, it is possible that some of these patients may have little to no circulating LDL-C. SUMMARY: As the new era of ultralow LDL-C levels ensues, it is imperative to understand the contribution of Lp(a)-C to measured LDL-C and the consequences of achieving ultralow or potentially absent LDL-C in the setting of elevated Lp(a) levels and possibly free apo(a). We review this concept and suggest avenues of research, including analyses of existing datasets in current clinical trials and new research studies, to understand its pathophysiological and clinical significance.
PURPOSE OF REVIEW: The measurement that is termed 'LDL-cholesterol' (LDL-C) includes the cholesterol content of lipoprotein(a) [Lp(a)-C], which can contribute approximately 30-45% to measured LDL-C levels as a percentage of its mass. We review the implications of achieved very low LDL-C levels in patients treated with potent LDL-C-lowering agents in the context of varying Lp(a) levels. RECENT FINDINGS: Combination therapy with statins, ezetimibe, and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors can lower LDL-C to unprecedentedly low levels. Recent PCSK9 trials have shown that routine achievement of mean LDL-C less than 50 mg/dl is feasible, along with the modest reductions in Lp(a). Many patients will achieve LDL-C less than 25 mg/dl with concomitantly elevated Lp(a) levels that contribute substantially to the measured 'LDL-C'. Therefore, it is possible that some of these patients may have little to no circulating LDL-C. SUMMARY: As the new era of ultralow LDL-C levels ensues, it is imperative to understand the contribution of Lp(a)-C to measured LDL-C and the consequences of achieving ultralow or potentially absent LDL-C in the setting of elevated Lp(a) levels and possibly free apo(a). We review this concept and suggest avenues of research, including analyses of existing datasets in current clinical trials and new research studies, to understand its pathophysiological and clinical significance.
Authors: Michael B Boffa; Tanya T Marar; Calvin Yeang; Nicholas J Viney; Shuting Xia; Joseph L Witztum; Marlys L Koschinsky; Sotirios Tsimikas Journal: J Lipid Res Date: 2019-09-24 Impact factor: 5.922
Authors: Sotirios Tsimikas; Sergio Fazio; Keith C Ferdinand; Henry N Ginsberg; Marlys L Koschinsky; Santica M Marcovina; Patrick M Moriarty; Daniel J Rader; Alan T Remaley; Gissette Reyes-Soffer; Raul D Santos; George Thanassoulis; Joseph L Witztum; Simhan Danthi; Michelle Olive; Lijuan Liu Journal: J Am Coll Cardiol Date: 2018-01-16 Impact factor: 24.094
Authors: Matthew T Mefford; Santica M Marcovina; Vera Bittner; Mary Cushman; Todd M Brown; Michael E Farkouh; Sotirios Tsimikas; Keri L Monda; J Antonio G López; Paul Muntner; Robert S Rosenson Journal: J Lipid Res Date: 2019-09-11 Impact factor: 5.922
Authors: Michael J Koren; Monica Florio; Patrick Maurice Moriarty; Seth J Baum; Joel Neutel; Martha Hernandez-Illas; Howard S Weintraub; Helina Kassahun; Stacey Melquist; Tracy Varrieur; Saptarsi M Haldar; Winnie Sohn; Huei Wang; Mary Elliott-Davey; Brooke M Rock; Tao Pei; Oliver Homann; Jennifer Hellawell; Gerald F Watts Journal: Nat Med Date: 2022-01-13 Impact factor: 87.241