In ACS patients on triple lipid-lowering therapy, an increase in Lp(a) was associated with a decreased probability of achieving LDL-C <50 mg/dL at one month (OR 0.98; 95% CI 0.97-0.99; p<0.01).
Cohort (n=303)
No
Does elevated lipoprotein(a) attenuate the LDL-C lowering efficacy of aggressive triple lipid-lowering therapy in statin-naïve ACS patients?
In ACS patients on aggressive triple lipid-lowering therapy, elevated or increasing Lp(a) levels significantly attenuate the LDL-C lowering response, reducing the likelihood of achieving optimal LDL-C targets.
Effect estimate: OR 0.98 (95% CI 0.97-0.99)
p-value: p=<0.01
Abstract Background Elevated lipoprotein(a) Lp(a) is a recognized independent risk factor for adverse cardiovascular outcomes in patients with coronary artery disease. While research regarding targeted Lp(a) reduction in the context of acute coronary syndrome (ACS) is ongoing, current standard of care for ACS, including high-intensity statins (HIS), can paradoxically increase Lp(a) levels. Although ezetimibe and PCSK9 inhibitors have demonstrated Lp(a)-lowering effects, bempedoic acid (BA) exhibits minimal impact. Limited data exist regarding the influence of elevated Lp(a) (defined as 50 mg/dl or higher) on LDL-C lowering in ACS patients receiving aggressive lipid-lowering therapy (LLT). Objective To evaluate changes in Lp(a) levels and their association with the LDL-C lowering response in ACS patients treated with a triple combination regimen of 40mg rosuvastatin, ezetimibe, and BA (REB regimen). Methods A retrospective analysis was conducted on data from statin-naïve ACS patients treated at our center with the REB regimen between March 2023 and December 2024. Inclusion criteria mandated consistent LLT adherence for one month and availability of both Lp(a) and LDL-C levels at index ACS admission and one-month post-ACS. The impact of changes in Lp(a) levels, specifically those exceeding 50 mg/dL, on mean LDL-C reduction and the proportion of patients achieving the LDL-C target of 50 mg/dL was assessed. Results Data from 303 patients were included in the analysis. Mean LDL-C at admission was 111.8±34.6 mg/dL, decreasing to 44.7±15.9 mg/dL at one month, representing a 60% reduction. At one month, 70.3% (213/303) of patients achieved LDL-C levels 50 mg/dL. Median Lp(a) increased from 28.1 mg/dL at admission to 64.6 mg/dL at one month. The prevalence of Lp(a) 50 mg/dL or higher was 28.7% at admission and 60.4% at one month. Logistic regression analysis revealed that an increase in Lp(a) was associated with a decreased probability of achieving LDL-C levels 50 mg/dL at one month Odds ratio=0.98 (0.97-0.99), p0.01. The mean LDL-C achieved at one month was significantly higher in patients with elevated Lp(a) /=50 mg/dL compared to those with 50 mg/dl, both at admission (54.3 ± 16.7 vs 40.9 ± 13.8, p0.001) and at one month (48.7 ± 16.1 vs 38.5 ± 13.3, p0.001). Conclusion In ACS patients treated with aggressive LDL-C lowering therapy, elevated Lp(a) levels are associated with an attenuated LDL-C response. The observed increase in Lp(a) during aggressive LDL-C lowering may impede the attainment of optimal LDL-C targets. These findings underscore the importance of Lp(a) monitoring in ACS patients and suggest that the incorporation of Lp(a)-lowering therapies may further optimize cardiovascular risk reduction. Additional research is warranted to evaluate the clinical implications of Lp(a)-lowering strategies in patients undergoing aggressive LDL-C management post-ACS.
Mahajan et al. (Sat,) conducted a cohort in Acute Coronary Syndrome (ACS) (n=303). Triple combination lipid-lowering therapy (REB regimen) was evaluated on Achieving LDL-C levels <50 mg/dL at one month (OR 0.98, 95% CI 0.97-0.99, p=<0.01). In ACS patients on triple lipid-lowering therapy, an increase in Lp(a) was associated with a decreased probability of achieving LDL-C <50 mg/dL at one month (OR 0.98; 95% CI 0.97-0.99; p<0.01).