Journal of clinical lipidology · 2026
Real-world threshold-based eligibility for emerging lipoprotein(a)-targeted therapies in chronic and acute coronary syndrome.
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Steinacher Eva, Bernhard Johannes, Wollmann Felix, Radl Victoria, Baumer Ulrike, Haider Patrick, Hofer Felix, Kazem Niema, Lenz Max, Hemetsberger Rayyan, Hengstenberg Christian, Niessner Alexander, Krychtiuk Konstantin A, Koller Lorenz, Speidl Walter S
Аннотация
BACKGROUND: Elevated lipoprotein(a) [Lp(a)] is a causal risk factor for atherosclerotic cardiovascular disease. Phase 3 programs are evaluating Lp(a)-lowering therapies using high entry thresholds; however, the real-world prevalence of trial-aligned Lp(a) thresholds in secondary prevention remains uncertain.
OBJECTIVE: To assess the prevalence of trial-aligned Lp(a) thresholds, national apheresis criteria, and the prognostic impact of elevated Lp(a) in a contemporary percutaneous coronary intervention (PCI) cohort.
METHODS: Patients undergoing PCI at a tertiary center with Lp(a) reported in nmol/L were analyzed. The proportion meeting trial-aligned thresholds (≥150, ≥175, ≥200 nmol/L) and the European Society of Cardiology/European Atherosclerosis Society risk-enhancing threshold (≥105 nmol/L) was estimated. National apheresis criteria were applied. 5-year major adverse cardiovascular events (MACE) and target lesion failure (TLF) were assessed.
RESULTS: Among 5942 patients with PCI, 25.2% had Lp(a) ≥105 nmol/L, with progressively smaller proportions meeting higher thresholds: 18.4% ≥150 nmol/L, 14.8% ≥175 nmol/L, 11.6% ≥200 nmol/L. Lp(a) concentrations were similar in chronic and acute coronary syndrome (CCS and ACS) (CCS, median 28.0 [IQR 9.0-118.5] vs ACS, 25.0 [IQR 9.0-96.5] nmol/L; P = .117). 1.8% to 6.1% met national apheresis criteria. Over 5 years, higher Lp(a) was independently associated with risk of MACE (adjusted hazard ratio [HR] per 1 SD 1.06 [95% CI 1.01-1.12]; P = .015) and TLF (adjusted HR per 1 SD 1.05 [95% CI 1.00-1.10]; P = .044).
CONCLUSION: Elevated Lp(a) was highly prevalent and independently predicted adverse 5-year outcomes in a contemporary PCI cohort. While a substantial proportion met trial-aligned Lp(a) thresholds for emerging therapies, few fulfilled apheresis criteria. Systematic Lp(a) testing may improve risk stratification and identify patients meeting trial-aligned Lp(a) thresholds for emerging therapies.
OBJECTIVE: To assess the prevalence of trial-aligned Lp(a) thresholds, national apheresis criteria, and the prognostic impact of elevated Lp(a) in a contemporary percutaneous coronary intervention (PCI) cohort.
METHODS: Patients undergoing PCI at a tertiary center with Lp(a) reported in nmol/L were analyzed. The proportion meeting trial-aligned thresholds (≥150, ≥175, ≥200 nmol/L) and the European Society of Cardiology/European Atherosclerosis Society risk-enhancing threshold (≥105 nmol/L) was estimated. National apheresis criteria were applied. 5-year major adverse cardiovascular events (MACE) and target lesion failure (TLF) were assessed.
RESULTS: Among 5942 patients with PCI, 25.2% had Lp(a) ≥105 nmol/L, with progressively smaller proportions meeting higher thresholds: 18.4% ≥150 nmol/L, 14.8% ≥175 nmol/L, 11.6% ≥200 nmol/L. Lp(a) concentrations were similar in chronic and acute coronary syndrome (CCS and ACS) (CCS, median 28.0 [IQR 9.0-118.5] vs ACS, 25.0 [IQR 9.0-96.5] nmol/L; P = .117). 1.8% to 6.1% met national apheresis criteria. Over 5 years, higher Lp(a) was independently associated with risk of MACE (adjusted hazard ratio [HR] per 1 SD 1.06 [95% CI 1.01-1.12]; P = .015) and TLF (adjusted HR per 1 SD 1.05 [95% CI 1.00-1.10]; P = .044).
CONCLUSION: Elevated Lp(a) was highly prevalent and independently predicted adverse 5-year outcomes in a contemporary PCI cohort. While a substantial proportion met trial-aligned Lp(a) thresholds for emerging therapies, few fulfilled apheresis criteria. Systematic Lp(a) testing may improve risk stratification and identify patients meeting trial-aligned Lp(a) thresholds for emerging therapies.