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Active pescatarian is troubled by a high lipoprotein(a) level

DEAR DR. ROACH: I’m a 56-year-old-female with very high lipoprotein(a) and am wondering if I should be as concerned about it as I am. I became aware of it in 2018) after I was tested as part of an executive-type physical. After almost two years of looking for a doctor to take my concern seriously, I was tested again. I also had a carotid ultrasound and a stress test (treadmill); both were apparently OK.

I’m now taking blood pressure medication. I started at 5 mg ramipril and am now at 10 mg, although my blood pressure isn’t normally high. I also take 20 mg of rosuvastatin, which contributed to my LDL going from 137 to 69 in about two months, and I take an 81-mg extended-release daily aspirin. At the recommendation of my doctor, I also have four glasses of red wine each week and take cod liver oil. My doctor told me that changing my already pretty good diet wouldn’t help, and he encouraged me to keep exercising, including running another half or full marathon. I’ve done many of both.

I’m very active, not overweight and a pescatarian for the past 28 years. My mother, father and brother died of heart attacks. Much of the research I have done is alarming. How concerned I should be, and should people be tested? — M.L.

ANSWER: Lp(a) — lipoprotein A, called “L P little A” — is a risk factor for heart disease and stroke. Several mechanisms are known that link Lp(a) with increased blockages in blood vessels as well as blood clots, both of which are instrumental for heart attacks and stroke. Unfortunately, there are no known treatments that reduce Lp(a) that have also been proven to reduce the risk of heart attack and stroke. As such, people with high levels of Lp(a) are recommended for other therapies that reduce heart disease risk. Statins, although they tend to increase Lp(a), nonetheless seem to reduce heart disease and stroke risk anyway, so I agree with the rosuvastatin (Crestor) you take. Your LDL level is below 70, so most experts would probably hold off on additional therapies for you at this time.

Those other therapies to be considered for people with elevated Lp(a) and who have not had such a good response to the statin include: aspirin, which you’re on; ezetimibe (Zetia); and evolocumab (Repatha). A new therapy, called antisense oligonucleotides, has been shown to reduce Lp(a) levels by up to 80%. It’s not yet clear whether this will translate to fewer heart attacks.

Testing is recommended for people with heart disease or a very strong family history, if they don’t have other cholesterol abnormalities, and for people whose cholesterol doesn’t go down appropriately with treatment.

Your pescatarian diet — that’s a vegetarian diet plus seafood — and the fact that you exercise are likely to reduce your risk, but neither the red wine nor the cod liver oil are proven to reduce heart disease risk. I never prescribe wine or other alcohol, despite a statistical association with lower heart disease risk.

In my opinion, a cardiologist with expertise in managing cholesterol abnormalities would be a useful consultant.

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