A Complex Case: Patient with Elevated Lp(a) and Debilitating Stroke

Abstract

Lead Author's Financial Disclosures Nothing to disclose. Study Funding None. Background/Synopsis DES, 43-year-old male, is referred for elevated lipoprotein(a) (Lp(a)), status-post ischemic left hemispheric stroke. There are potential interventions but insufficient evidence to make strong recommendations. Objective/Purpose To determine an appropriate treatment plan tailored to DES' situation. Methods This is a review of treatment options, barriers to care, and ethical considerations rendering this scenario complex. Results DES' medical history includes obesity, smoker, type 2 diabetes mellitus, hypertension, legal blindness, and subsequent ischemic left hemispheric stroke with residual global aphasia and right-sided hemiparesis. DES will remain a long-term care facility resident. He was referred by neurology after identifying an Lp(a) level greater than three times the upper limit of normal. Prior to initiating atorvastatin 80mg daily, DES' lipid levels are identified in Table 1. The 2018 AHA/ACC/Multisociety Guideline on the Management of Blood Cholesterol (1) supports using Lp(a) as a risk-enhancing factor to inform clinical decision-making, preventing atherosclerotic cardiovascular disease (ASCVD) in adults with at least 5% 10-year ASCVD risk, per the Pooled Cohort Equation. The National Lipid Association (NLA) Statement: Use of Lipoprotein(a) in Clinical Practice (2), supports testing Lp(a) in younger patients with prior cardiovascular events (CVE) and intensive low-density lipoprotein cholesterol (LDL-C) lowering, especially with proprotein convertase subtilisin-kexin 9 (PCSK9) monoclonal antibodies. The NLA mentions FDA criteria for lipoprotein-apheresis. Ongoing investigations of Lp(a)-lowering pharmacotherapy involve our program's HORIZON study of pelacarsen (3), testing whether it is superior to placebo in reducing CVE's in adults with prior myocardial infarction, stroke, symptomatic peripheral arterial disease, plus elevated Lp(a). Conclusions We considered whether additional preventive strategies directed at DES' Lp(a) is worthwhile after a debilitating stroke. Guidelines do not recommend care beyond closely monitoring lipid levels. Apheresis becomes available when LDL-C is greater than 110mg/dL, per FDA criteria. Participation in clinical decision-making and randomized placebo controlled clinical trials (RCT) is problematic. The team recommended closely monitoring lipid levels, but did not recommend additional pharmacotherapy, apheresis or RCTs. DES' diminished functional capacity, incomplete social support as a long-term care facility resident, and unclear indications for additional therapy guided our decision-making. DES' scenario enabled a discussion regarding clinical decision-making, clinician-patient discussions, patient engagement, socioeconomic/racial disparities, and limitations of guidelines within caring for complex patients. Nothing to disclose.