Should LP (A) be included in the cardiovascular risk calcator?

Should LP (A) be measured or not, lipoprotein associated with increased cardiovascular risk? Furthermore, How to use this information in CV risk assessment?

L’American Heart Association recently developed the Prevent score (Predicting Risk of Cardiovascular EVENT), an update of group cohort equations. However, But none of these two methods of calculating CV risk include the values of LP (A).

A recent analysis published in the JAMA Cardiology examined whether the addition of the LP (A) to the prevent. However, equations would improve risk prediction. In addition, It turns out that the inclusion of this lipid parameter leads to a modest improvement at the level of the population. For example, but seems more useful for a personalized risk assessment, especially in individuals at lower risk.

“Our results validate the equations take the population level. Moreover, show that they work well in people with should lp (a) included cardiovascular or without high levels of LP (A),” said Dr. Furthermore, Harpreet Bhatiaprincipal author of the study, University of California in San Diego, at Medscape Medical News.

“Although I think our results do not show that the addition of the LP (A) to the expected equations is relevant. For example, they confirm that at the individual level, the LP (A) can provide additional information,” he added.

Harpreet Bhatia explains that the prevent equations will probably become the new paradigm of the stratification of risk in primary prevention in the United States. However, replacing the group equations used for many years.

It assumes that the LP (A) has not been included in these risk scores because the databases on which. Furthermore, the equations are based does not probably contain these values.

The prevent equations have deleted taking into account the race. Consequently, the ethnic origin, recognizing that these are more social constructions. should lp (a) included cardiovascular However, we know that the levels of LP (A) vary according to genetic ancestry, he said. Furthermore, Harpreet Bhatia believes that LP (A) should be systematically tested at least once in all adults: “For those of us who practice preventive cardiology. However, lipidology, this can change our clinical management. Furthermore, »»

Should lp (a) included cardiovascular

Recommendations

The current recommendations of the AHA/ACC of 2018 do not recommend a systematic screening of the LP (A). but consider it as an aggravating factor of risk; Updated recommendations are expected in the year.

On the other hand. the recommendations of the European Cardiology Society Canada and National Lipid Association In the United States recommend the LP (A) measure.

In the study. Harpreet Bhatia and his colleagues examined data from the Multi-Ethnic Study of Atherosclerosis (MESA), an American study of 6,670 people started in 2000, and the UK Biobank, a study of should lp (a) included cardiovascular more than 500,000 people in the United Kingdom started around 2006.

Participants did not have a cardiovascular disease known at the start, and most had an LP measurement (A). The risk thresholds used in the study were based on group cohort equations:

• Low risk: <5 %;

• Limit: 5 % -7.5 %;

• Intermediary: 7.5 % -20 %;

• High: ≥ 20 % (risk at 10 years of cardiovascular disease).

“The prevent equations are generally doing a good job”

“Basically. what we have observed is that the equations are generally classifying people well in the right risk categories at 10 years,” said Harpreet Bhatia.

However. within each category, if the LP (A) was high, the cardiovascular risk increased compared to people with a low LP (A), sometimes significantly.

Researchers also used the index Net Reclassification Index (NRI) to assess whether the addition of LP (A) made it. possible to should lp (a) included cardiovascular better classify the risk. Result: LP (A) has enabled a modest improvement in risk prediction.

Regarding atherosclerotic cardiovascular disease (ASCVD), the addition of LP (A) has correctly reclassative about 6 % of patients. For coronary disease, with which LP (A) is most strongly associated, the NRI was around 8 %.

Another measure, index C, has not shown a significant modification with the addition of the LP (A). “Our results suggest a certain improvement in risk prediction with LP (A). especially in people at low risks,” noted Harpreet Bhatia, describing this “intriguing”.

He does not think that new equations including LP (A) are necessary to create new equations. stresses that statins are recommended more strongly for patients at intermediate or high risks, and more weakly for those at low risk in the presence of aggravating factors. “A low-risk person but with a high LP (A) could become eligible for statins,” he should lp (a) included cardiovascular notes.

LP measurement (A): a confirmed interest

Harpreet Bhatia already uses LP (A) levels in his practice. The test is simple, widely available, and the majority of people will only need to do it once.

In general, those with low or high levels will remain in these long -term categories. People with intermediate levels (30-50 mg/DL. 75-125 Nmol/L) may require a monitoring test in the event of changes affecting the LP (A) (menopause, kidney or thyroid disease …).

In an editorial accompanying the publication, Dr. Donald M. Lloyd-Jones(University of Boston) and Dr. Amit khera(University of Texas Southwestern) welcomed this validation of equations take in modern populations and real clinical samples.

Regarding the direct inclusion of the LP (A) in the provision equations. their opinion joins that of Harpreet Bhatia: “It seems useless”, they wrote.

However, they support a unique measure in each adult to better understand and personalize should lp (a) included cardiovascular the risk. “LP (A) is indeed an aggravating factor in the risk of atherosclerosis, probably causal. Its absence does not exonerate traditional risk factors. but its presence can amplify and personalize this risk, and help guide preventive treatments, ”they conclude.

Other comments

The Pr Nathan Wong(University of California in Irvine). commented the study: the prevent score provides well for cardiovascular events, whether or not there are high levels of LP (A).

However. the more marked role of LP (A) in low-risk people highlights the importance of extending screening to a wider population, beyond high-risk patients alone. He joins Harpreet Bhatia: LP (A) is more useful at the individual level than at the population level. However. he thinks that a risk score including LP (A) could be useful for personalizing treatments, especially in LP (A) unidentified as at high risk patients.

Nathan Wong and his colleagues recently published such a should lp (a) included cardiovascular score. They showed that a 25 mg/dl of LP (A) is associated with a 23 % increase in the risk of cardiovascual accident. Levels ≥ 75 mg/dl were associated with a risk multiplied by 2, including a risk of stroke multiplied by 2.5 compared to levels <25 mg/dl.

They also showed that the addition of LP (A) to the cardiovascular risk calculator (grouped cohort equations) properly reclaimed. 45 % of patients at borderline-intermediate risk who had an event as at high risk.

However, 24 % without events was wrongly reclassified as at high risk (NRI = 21 %).

Nathan Wong quotes an example: an African-American man of 65 years with an LP (A) of 80 mg/DL has. a cardiovascular risk at 10 years of 18 % when the LP (A) is not taken into account. And, this risk goes to 24 % by integrating it.

“According to the current recommendations. should lp (a) included cardiovascular this patient would clearly be a candidate for treatment with Statine, which was not as obvious without taking into account the LP (A),” he said.

Recent studies also show that the identification of a high LP (A) increases the use of hypolipaning therapies.

“We do not practice medicine on populations. We practice it on individuals. and for some, a risk score integrating LP (A) can change their risk category in a significant way, ”underlines Professor Wong.

Article translated and adapted from the American should lp (a) included cardiovascular edition of Medscape.com .

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