The heart disease triple-threat your doctor doesn’t routinely check for

Not all cholesterol risk is explained by LDL (bad) cholesterol levels. It turns out there’s another factor that impacts the significance of any LDL number obtained. That factor is Lipoprotein A also known as Lp(a).

Bob Harper, the celebrity trainer on America’s Biggest Loser, learned about this risk factor the hard way. The lean, athletic Mr. Harper, suffered a massive heart attack while working out. He had always had normal cholesterol levels and is only 52 years old. Until he had his heart attack, he had no idea his Lipoprotein A was elevated. The one clue? Bob has a strong family history of heart disease.

You can think of lipoprotein A, or Lp(a) for short, as an extra protein that can attach itself to LDL particles and make them much more toxic — and much more likely to accumulate in arteries. Lp(a) is not related to LDL levels at all, so unless you check for it with a blood test, you don’t know if it’s an additional risk factor for you.

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Who’s at risk from Lipoprotein A?

About 20% of the population has Lp(a) levels that are too high. These people often have a family history of heart disease with several family members experiencing early or recurrent cardiovascular events.

If you have a family history of heart disease – especially in younger or in multiple relatives – you should absolutely be checked for this risk factor.  If you are someone who has elevated Lp(a), you should notify your first-degree relatives, because they should all be checked for this risk factor as well.

That’s because elevated Lp(a) levels triple heart disease risk. You read that right. Triple.

Normal Lp(a) levels fall below 30 mg/dL.  Risk goes up with Lp(a) levels above 80 and rises sharply with levels above 150.

Lp(a) is genetically driven and is frustratingly hard to lower. Niacin and PCSK9 inhibitors (like Praluent® and Repatha®) have yielded modest reductions. However, niacin in the high doses required to affect Lp(a), can have many side effects and PCSK9s are exceedingly expensive, so the chance that this becomes a routine therapy in the near future is low.

The way we currently “treat” abnormal Lp(a) levels is to aggressively lower LDL. Because if you don’t have much LDL around, there’s not a lot of it that can become toxic. There are no specific guidelines on how aggressive to be with LDL lowering in someone with elevated Lp(a), but my approach is to move patients down by one category in terms of LDL goal.

What do cardiologists do about Lipoprotein A?

In people without any risk factors for heart disease, most cardiologists would agree that keeping LDL below 130 is reasonable. Once you have one or more traditional risk factors for heart disease (like smoking, high blood pressure, low HDL, etc.), aiming for an LDL below 100 is better. If you have known heart or vascular disease (you’ve had a heart attack, a stent, bypass surgery, a stroke, etc.) or you’re diabetic, aiming for an LDL below 70 is ideal.

When you add abnormal Lp(a) into the mix, a reasonable strategy is to aim for an LDL below 100 for people without any other risks, below 70 for those with traditional risk factors, and closer to 50 for those with diabetes and/or cardiovascular disease.

ScenarioLDL goal with normal Lp(a)LDL goal with elevated Lp(a)
No risk factors<130 mg/dL<100 mg/dL
Some risk factors<100 mg/dL<70 mg/dL
Known heart or vascular disease or diabetes<70 mg/dL<50 mg/dL

Patients with elevated Lp(a) need to attain lower cholesterol levels, so they are typically placed on higher statin doses — making them more prone to developing medication side effects.

What can you do about Lipoprotein A?

Anyone facing the Lp(a) threat should do everything they can to improve diet and lifestyle — not only to help lower their LDL naturally and reduce the need for high dose medications but to also leverage all the other risk reduction that goes along with eating better overall.

You may be tired of hearing advice about diet, but the impact of food can be dramatic…

Related: The sweet snack that slays high cholesterol

A recent study showed that nearly 50% of all deaths due to heart disease, stroke and diabetes can be attributed to diet — not to a lack of medications — but to the wrong foods.  So, eating right is not just a good idea, it’s critical to healthy longevity.

Which is why I wanted to remind you of the four key, heart-healthy nutrients that you should add to your diet:

Plant sterols: Plant sterols can be found naturally in many grains, nuts, seeds, veggies and fruits and they have powerful cholesterol-lowering properties.

Omega-3 fatty acids: You know it as the good kind of fat. These fatty acids are essential to your health and are found in fish like tuna, salmon, and halibut — as well as in nuts and seeds, like walnuts, flax and chia.  In addition to helping lower blood pressure and cholesterol, Omega-3 also plays a vital role in maintaining brain health.

Antioxidants: Found naturally in vegetables, fruits, coffee and wait for it… chocolate and wine, antioxidants help prevent and stop cell damage. This simply means that antioxidants work to fight off substances that harm your body. By incorporating these into your diet, you’re helping your body fight off disease and chronic ailments.

Whole Food Fiber: This-plant based nutrient is found in beans and grains, as well as fruits and vegetables, and helps keep food moving through your body. Fiber also aids in regulating blood sugar levels and lowering cholesterol.

Together, these four nutrients and food that contain them are key to keeping the main drivers of heart disease — diabetes, high blood pressure, and high cholesterol — at bay.

And the data is clear:  When you increase your intake of these nutrients while limiting your intake of foods that are high in added sugars and animal fat, you can make more of an impact on your heart health than you could with any preventative medications.

A great patient resource for more information and the latest research news about Lp(a) is the Lipoprotein A Foundation website. And learn more about improving cholesterol with food, made easier, at Step One Foods.

Dr. Elizabeth Klodas MD, FACC

By Dr. Elizabeth Klodas MD, FACC

"Diet is a major driver of high cholesterol, but instead of changing the food, we prescribe medications. This never seemed logical to me.” Dr. Klodas has dedicated her career to preventive cardiology. Trained at Mayo Clinic and Johns Hopkins, she is the founder and Chief Medical Officer for Step One Foods. Dr. Klodas is a nationally sought out speaker and has an active role at the American College of Cardiology. Her clinical interests include prevention of heart disease and non-invasive cardiac imaging and she has published dozens of scientific articles throughout her career. Dr. Klodas has been featured on CNN Health for her mission to change how heart disease is treated. An independent study performed at leading medical institutions affirmed the ability of Step One Foods to deliver measurable and meaningful cholesterol-reduction benefits in the real world. The results of the trial were presented at the 2018 American Heart Association’s Scientific Sessions. Dr. Klodas has also authored a book for patients, "Slay the Giant: The Power of Prevention in Defeating Heart Disease," and served as founding Editor-in-Chief of the patient education effort of the American College of Cardiology. In addition to her practice and her duties at Step One Foods, she also serves as medical editor for webMD.