How Do Lipoprotein(a) Concentrations Affect Clinical Outcomes for Patients With Stable Coronary Artery Disease Who Underwent Different Dual Antiplatelet Therapy After Percutaneous Coronary Intervention?

Abstract

Background Lp(a) (lipoprotein[a]) plays an important role in predicting cardiovascular events in patients with coronary artery disease through its proatherogenic and prothrombotic effects. We hypothesized that prolonged dual antiplatelet therapy (DAPT) might be beneficial for patients undergoing percutaneous coronary intervention who had elevated Lp(a) levels. This study aimed to evaluate the effect of Lp(a) on the efficacy and safety of prolonged DAPT versus shortened DAPT in stable patients with coronary artery disease who were treated with a drug‐eluting stent. Methods and Results We selected 3201 stable patients with CAD from the prospective Fuwai Percutaneous Coronary Intervention Registry, of which 2124 patients had Lp(a) ≤30 mg/dL, and 1077 patients had Lp(a) >30 mg/dL. Patients were divided into 4 groups according to Lp(a) levels and the duration of DAPT therapy (≤1 year versus >1 year). The primary end point was major adverse cardiovascular and cerebrovascular event, defined as a composite of all‐cause death, myocardial infarction, or stroke. The median follow‐up time was 2.5 years. Among patients with elevated Lp(a) levels, DAPT >1 year presented lower risk of major adverse cardiovascular and cerebrovascular event and definite/probable stent thrombosis compared with DAPT ≤1 year. In contrast, in patients with normal Lp(a) levels, the risks of major adverse cardiovascular and cerebrovascular event and definite/probable stent thrombosis were not significantly different between the DAPT >1 year and DAPT ≤1 year groups. Prolonged DAPT had 2.4‐times higher risk of clinically relevant bleeding than shortened DAPT in patients with normal Lp(a) levels, although without statistical difference. Conclusions In stable patients with coronary artery disease, who underwent percutaneous coronary intervention with a drug‐eluting stent, prolonged DAPT was associated with reduced risk of cardiovascular events among those with elevated Lp(a) levels, whereas it did not show statistically significant evidence of benefit for reducing ischemic events and tended to increase clinically relevant bleeding among those with normal Lp(a) levels.

Lipoprotein(a) Is Associated with Thrombus Burden in Culprit Arteries of Younger Patients with ST-Segment Elevation Myocardial Infarction

“…A pro-thrombotic state contributes to residual cardiovascular risk. In a large retrospective registry, patients with stable coronary artery disease and Lp(a) >30 mg/dL were found to have reduced cardiovascular events with prolonged duration (>1 year) of dual anti-platelet therapy after PCI [10]. Clinically relevant bleeding was not increased in those with elevated Lp(a) with prolonged dual anti-platelet therapy, in contrast to those with normal Lp(a) [10].…”

“…In a large retrospective registry, patients with stable coronary artery disease and Lp(a) >30 mg/dL were found to have reduced cardiovascular events with prolonged duration (>1 year) of dual anti-platelet therapy after PCI [10]. Clinically relevant bleeding was not increased in those with elevated Lp(a) with prolonged dual anti-platelet therapy, in contrast to those with normal Lp(a) [10]. While addition of low-dose rivaroxaban to aspirin for secondary prevention significantly reduced cardiovascular events in a large randomized trial, Lp(a) was not measured [11].…”

Small apolipoprotein(a) isoforms may predict primary patency following peripheral arterial revascularization

“…While we wait for this data, new studies now suggest the benefit of DAPT in patients with high Lp(a) 40 . Particularly, recent outcomes in these patients undergoing percutaneous coronary intervention (PCI), showed that prolonged DAPT (>1 year) reduced ischemic cardiovascular events, all-cause mortality, cardiac mortality, and definite/probable stent thrombosis, without increase in clinically relevant bleeding risk compared with ≤ 1-year DAPT 41 . Data from this small study cohort raise the question whether we need to rethink risk assessment and post-operative management in patients high Lp(a) and small apo(a) size undergoing lower extremity interventions.…”

Aspirin and lipoprotein(a) in primary prevention

“…One study, however, of individuals undergoing percutaneous coronary intervention (PCI), observed that individuals with higher Lp(a) had accelerated fibrin generation, greater clot strength, and increased platelet aggregation in vivo, suggesting a net pro-platelet effect of Lp(a) [28]. Another study of individuals undergoing PCI observed a benefit to prolonged dual antiplatelet therapy in individuals with high Lp(a) but not in individuals with normal Lp(a) [29]. The potential antifibrinolytic and pro-platelet effects of Lp(a) provide a rationale for a particular benefit from aspirin therapy with increased thrombotic risk and possibly decreased bleeding risk in this population.…”