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Lp(a) Lipoproteins/Risk Factor For Heart Disease
Cardiovascular, or heart, disease is the leading cause of death in America. Dr. Anthony Patrello discusses what the risks of heart disease are and how they are determined.
Featured Speaker:
Anthony Patrello, MD
Dr. Anthony Patrello is an interventional cardiologist at The Hudson Valley Heart Center and the Director of Cardiovascular Services at St. Lukes Cornwall Hospital. He has particular expertise at treating complex coronary artery disease, peripheral vascular disease, heart valve disease, as well as preventative medicine. He is board certified in cardiovascular disease, nuclear cardiology, echocardiography, interventional cardiology, and internal medicine. He has received the honor of being elected a Fellow of the American College of Cardiology and the Society for Cardiovascular Angiography and Interventions. Dr. Patrello began his medical training at The Mount Sinai School of medicine, where he received his medical degree with honors. He completed a residency in internal medicine at The Columbia University Medical Center. He then moved to Chicago where he was fellowship trained at Northwestern University. Dr. Patrello then returned to New York City and completed a fellowship in interventional cardiology at The Mount Sinai Medical Center. Dr. Patrello is married to a visual effects artist and they have two young children. The Hudson valley native is excited to provide cutting edge care to the community where he was raised. Transcription:
Lp(a) Lipoproteins/Risk Factor For Heart Disease
Prakash Chandran: Cardiovascular disease is the leading cause of death for both men and women in America. Every year, more than 600,000 people die of heart disease and that's one out of every four deaths. Unfortunately, the majority of people with this disease are living unaware of their risks, but what are these risks and how are they determined?
We're going to talk about it today with Dr. Anthony Patrello, the Medical Director of Cardiovascular Services at Montefiore St. Luke's Cornwall. This is Doc Talk, the podcast from Montefiore St. Luke's Cornwall. My name is Prakash Chandran. So first of all, Dr. Patrello, it is great to have you here today. Let's just start with a high level question around what are lipoproteins.
Dr. Anthony Patrello: Well, thank you very much for having me today. Lipoproteins in the cells are just basically spherical particles that carry lipids or fats in the body. They're created of fats and protein. In particular, the lipoprotein that we're most interested in now recently is a lipoprotein called lipoprotein (a) or LP(a). LP(a) is a type of lipoprotein that is comprised of an LDL-like particle, and your LDL is your bad cholesterol, with a second protein called this apolipoprotein A or APO(a) coiled around it.
And the reason why this is important is because APO(a) is thought to increase both atherogenicity, that means the ability for the vessels to accumulate cholesterol plaque, and thrombogenicity, which is the ability for the vessels to clot. So it increases the plaque buildup and the clotting inside an artery, which is a major risk factor for heart attack.
Prakash Chandran: So getting into a little bit more detail, how do you actually go about measuring LP(a)?
Dr. Anthony Patrello: So you can measure the LP(a) itself through a blood test, a very simple blood test. Normal values would be less than 30. Between 30 and 50 is sort of an intermediate range. And your risk of having a vascular event increases significantly above the level of 50. And then the higher you get, the higher your risk.
And the reason why this is important to check individually is because checking your regular cholesterol will not tell you what your LP(a) is. You can have a very normal cholesterol, but have a very elevated LP(a). So you can be led into a false sense of security that you may be at low risk because your cholesterol is okay. But really, your risk is elevated and it's hidden and we can sort of bring it out and refine that risk by checking this individual lab test.
Prakash Chandran: Understood. So let's talk a little bit about who should be getting this test and how they can go about getting it.
Dr. Anthony Patrello: It's a great question. Really, anybody is eligible and we should think about obtaining the test in basically any patient. There's a specific set of the population who I think it's particularly useful for, and those are patients where the answer is really going to change our treatment paradigm for them. Those are patients who we're looking for this hidden risk.
One class of patients or people who've had premature heart disease in the family. So that is having a male first-degree relative who had a heart attack or a heart event age 55 or under, or having a first-degree woman in the family at age 65 or under. If there's a family history, if you knew that there's someone in your family who had an elevated LP(a), this can be genetically passed down. So you're at a little bit of a higher risk of having an LP(a) yourself.
Familial hypercholesterolemia, so these are people who have astronomically elevated LDL cholesterol or bad cholesterol levels despite not having a poor diet. This is just genetically programmed. Very, very high LDL levels. They tend to have higher LP(a)s as well. If you yourself had a heart event, despite having excellent cholesterol levels, so if you had a heart attack, but your cholesterol has always been excellent and it's confusing as to why that happened, perhaps you have an LP(a) that's elevated and that's what's causing that.
And then the final group, which I think is the most useful, are people who have an intermediate ten-year risk of having a heart event. So people who basically were on the fence should we be treating them with cholesterol medicine or not. And sometimes, it's not entirely clear based on their regular cholesterol levels. So we check this as sort of a tie-breaker. And if the level is low, then maybe we can just stick with diet and exercise. But if the level is high, that somebody where their risk is higher than we would normally understand just by their cholesterol levels and that's somebody who maybe we want to treat more aggressively.
How you can get the test done, it can be ordered in a blood test, separate from your regular cholesterol profile. But usually, you have to ask or bring up the discussion with your heart doctor. A lot of cardiologists don't check it individually or on their own independently, so asking them and bringing it up and making the conversation is helpful.
Prakash Chandran: Okay. So for myself, for example, my father had a cardiovascular event, I believe, when he was like 67. But his father, so my grandfather, died of a heart attack when he was 55. So obviously it's on my mind. I'm 40 years old and, you know, I do what most people do, which is go to their primary care physician probably once, maybe twice a year and get the blood work done. Is that where I would be getting this? Or do I have to ask for something in addition to going to my primary care provider?
Dr. Anthony Patrello: So there are some primary care doctors who are very savvy in terms of cardiovascular risk reduction and really are sub-specialists within epidemiology as well. And there are certainly some primary care doctors would be very comfortable in ordering this test. There's some who are comfortable in ordering it. And, if it's normal, then they're okay with it. And if it's abnormal, then refer to the cardiologist. And then there are some who say, "You know what? This is really out of the scope of what I'm comfortable doing. If you're really interested in getting a refined risk profile, you know, perhaps used to see a cardiologist." So I think it really depends on the comfort level of your own primary care doctor.
Prakash Chandran: Understood, but I think this is something that feels important enough for you to take control of, especially if you have some of the risk factors that you mentioned, wouldn't you say?
Dr. Anthony Patrello: I would absolutely agree with that. There's only a certain amount that the normal testing that we do can really tell us about your risk. And if we're really worried about your risk, for whatever reason and family history is usually the most common of those reasons, then really trying to refine that risk is really helpful. And this is one of the types of tests that can be helpful in that regard. So certainly, if it hasn't been brought up to you by your doctor, then bringing it up to your doctor would be the way to go.
Prakash Chandran: I've also heard about this notion of a proactive CT angiogram, I guess, measuring like certain calcification levels. Is this kind of the same or is that something that should be done coupled with this LP(a) test?
Dr. Anthony Patrello: That's an excellent question. So it's a different test, the CAT scan to look for calcium buildup in the arteries of the heart. That's looking for early evidence of atherosclerosis. I think if you're going to do that, and then you find that there is this elevated calcium score, elevated calcium buildup in the arteries, you probably don't also need the LP(a), because you've already identified somebody who is at a little bit of a higher risk and you've already stated that, "Okay, this is somebody who I'm going to treat more aggressively."
The time I would use the LP(a) is if you didn't want to get a CAT scan, which is a radiation exposure. It's not a high radiation exposure, but it's not a zero radiation exposure either. Or the calcium score was zero, which means that there's no elevated plaque yet, yet we still want to refine and we're still on the fence about whether or not the person should be treated with a cholesterol medicine aggressively to lower their cholesterol levels, that's where the LP(a) would come into play.
Prakash Chandran: Okay. That makes sense. So let's say you get the results back and your levels of LP(a) are a little bit high. What sorts of treatment options are available to you?
Dr. Anthony Patrello: So I think the reason why that most cardiologists or most doctors aren't checking it is because right now there's actually no great treatment for it. What it does tell us though is that this is a person who is at a higher risk overall. So basically, the treatment right now is just to address all of their risk factors more aggressively.
If they're overweight and you were kind of playing around with their weight a little bit, now you want to be really aggressive in trying to get their weight down. If their cholesterol has been kind of borderline and you've been on the fence about trying to lower that, this is somebody who you really want to lower it. And if you did want to lower it to lower than a hundred, perhaps you want to get to less than 70. If you want to get it less than 70, perhaps now you want to get it less than 40. So it's just going to augment what you're already doing for them.
There are some medications called PCSK9 inhibitors that can lower the LP(a) a little bit. The clinical significance of that is unclear. And there are clinical trials going on right now for dedicated treatment to lower LP(a) and those trials should be completed within next couple of years. And I think that's really going to move the needle in terms of risk reduction when those trials are completed and we have new therapeutics on the horizon.
Prakash Chandran: Okay. Well, that's good. You talked about doing all of the things that potentially lower your risk profile. One of them being potential diet and exercise. Do you have best practices for people around what they should be consuming and how often they should be exercising?
Dr. Anthony Patrello: Yes. So we should be exercising about 30 minutes a day, at least three days a week. And exercise is an activity that I would classify something that gets your heart rate elevated. So certainly, a slow walk in the neighborhood I think is good in terms of conditioning. But it's probably not really going to move the needle in terms of exercise. It's something that you really do want to get your heart rate elevated. Now, if you're so de-conditioned that that's what gets your heart rate elevated, then certainly that would count.
In terms of diet, there's certainly a ton of fad diets out there that people are using in order to lose weight. And there's tons of different ways to lose weight. But I think that the tried and true way in order to lose weight, keep weight off and do it in a healthy way without elevating your cholesterol levels, which some of the fad diets can, is using sort of a Mediterranean kind of a diet. You know, fruits, nuts, grains, vegetables, baked food, olive oil, nothing fried, minimizing dairies, minimizing carbs, minimizing pastas, and that kind of thing. And eating more of a well-balanced diet, monitoring portion control -- portion control is a major issue in this country -- trying to focus on those pillars.
Prakash Chandran: And is there anything that you can consume that will naturally help you lower this LP(a)?
Dr. Anthony Patrello: There is not. There is one medicine that has been used in the past called niacin. It's an old medicine that actually can lower LP(a) a little bit. But the problem is that it actually wasn't shown that lowering the LP(a) with niacin actually improved your event rate. So it didn't actually lower your risk of heart attack. And there's a ton of side effects that can happen with niacin. So that's not even recommended anymore. And so there's nothing really in the diet that can lower it. Really it tells you that you just want to lower your overall cholesterol even more aggressively because you have this risk factor.
Prakash Chandran: Okay. And one more thing I wanted to ask is how often should you be getting this LP(a) test?
Dr. Anthony Patrello: Right now, since there's no treatment for it that can lower your LP(a), I think it's a good one-time test to have. So I don't think it's something that we need to follow. If it's elevated, then we know that it's elevated and we know that that risk factor is there. Nothing that we're going to be doing is really going to be aimed at lowering that actual number. The whole goal of our treatment is going to be lowering your overall risk outside that number. So I think that really just a one-time check would be enough.
Prakash Chandran: Okay. And just as we close here, you've seen, I'm sure, so many patients throughout your career. If you had to share one piece of advice with them based on everything that you knew, what might that be?
Dr. Anthony Patrello: I think it goes back to the thing that you led with in the open is that, from an actuarial standpoint, your risk of dying from heart disease is greater than your risk of dying of anything else. And it's actually greater than the risk of you dying from the number two, number three, and then number four things on the list combined. So if you'd asked me statistically speaking, "How am I likely to die?" It's going to be probably from heart disease.
So if you would ask, "Well, what can I do to prolong my life?" Most likely, statistically speaking, you're most likely to die of heart disease, then your focus should be on trying to minimize your risk of heart disease. And I think taking it from that standpoint, I think gets people more motivated in trying to lead a healthier life.
Prakash Chandran: Well, Dr. Patrello, I think that is the perfect place to end. Thank you so much for your time today. We truly appreciate it.
That's Dr. Anthony Patrello, the Medical Director of Cardiovascular Services at Montefiore St. Louis Cornwall. For more information, head to MontefioreSLC.org. If you found this podcast helpful, please share it on your social channels and be sure to check out the entire podcast library for topics of interest to you.
Thanks for listening to this episode of Doc Talk. My name is Prakash Chandran, and we'll talk next time.
Lp(a) Lipoproteins/Risk Factor For Heart Disease
Prakash Chandran: Cardiovascular disease is the leading cause of death for both men and women in America. Every year, more than 600,000 people die of heart disease and that's one out of every four deaths. Unfortunately, the majority of people with this disease are living unaware of their risks, but what are these risks and how are they determined?
We're going to talk about it today with Dr. Anthony Patrello, the Medical Director of Cardiovascular Services at Montefiore St. Luke's Cornwall. This is Doc Talk, the podcast from Montefiore St. Luke's Cornwall. My name is Prakash Chandran. So first of all, Dr. Patrello, it is great to have you here today. Let's just start with a high level question around what are lipoproteins.
Dr. Anthony Patrello: Well, thank you very much for having me today. Lipoproteins in the cells are just basically spherical particles that carry lipids or fats in the body. They're created of fats and protein. In particular, the lipoprotein that we're most interested in now recently is a lipoprotein called lipoprotein (a) or LP(a). LP(a) is a type of lipoprotein that is comprised of an LDL-like particle, and your LDL is your bad cholesterol, with a second protein called this apolipoprotein A or APO(a) coiled around it.
And the reason why this is important is because APO(a) is thought to increase both atherogenicity, that means the ability for the vessels to accumulate cholesterol plaque, and thrombogenicity, which is the ability for the vessels to clot. So it increases the plaque buildup and the clotting inside an artery, which is a major risk factor for heart attack.
Prakash Chandran: So getting into a little bit more detail, how do you actually go about measuring LP(a)?
Dr. Anthony Patrello: So you can measure the LP(a) itself through a blood test, a very simple blood test. Normal values would be less than 30. Between 30 and 50 is sort of an intermediate range. And your risk of having a vascular event increases significantly above the level of 50. And then the higher you get, the higher your risk.
And the reason why this is important to check individually is because checking your regular cholesterol will not tell you what your LP(a) is. You can have a very normal cholesterol, but have a very elevated LP(a). So you can be led into a false sense of security that you may be at low risk because your cholesterol is okay. But really, your risk is elevated and it's hidden and we can sort of bring it out and refine that risk by checking this individual lab test.
Prakash Chandran: Understood. So let's talk a little bit about who should be getting this test and how they can go about getting it.
Dr. Anthony Patrello: It's a great question. Really, anybody is eligible and we should think about obtaining the test in basically any patient. There's a specific set of the population who I think it's particularly useful for, and those are patients where the answer is really going to change our treatment paradigm for them. Those are patients who we're looking for this hidden risk.
One class of patients or people who've had premature heart disease in the family. So that is having a male first-degree relative who had a heart attack or a heart event age 55 or under, or having a first-degree woman in the family at age 65 or under. If there's a family history, if you knew that there's someone in your family who had an elevated LP(a), this can be genetically passed down. So you're at a little bit of a higher risk of having an LP(a) yourself.
Familial hypercholesterolemia, so these are people who have astronomically elevated LDL cholesterol or bad cholesterol levels despite not having a poor diet. This is just genetically programmed. Very, very high LDL levels. They tend to have higher LP(a)s as well. If you yourself had a heart event, despite having excellent cholesterol levels, so if you had a heart attack, but your cholesterol has always been excellent and it's confusing as to why that happened, perhaps you have an LP(a) that's elevated and that's what's causing that.
And then the final group, which I think is the most useful, are people who have an intermediate ten-year risk of having a heart event. So people who basically were on the fence should we be treating them with cholesterol medicine or not. And sometimes, it's not entirely clear based on their regular cholesterol levels. So we check this as sort of a tie-breaker. And if the level is low, then maybe we can just stick with diet and exercise. But if the level is high, that somebody where their risk is higher than we would normally understand just by their cholesterol levels and that's somebody who maybe we want to treat more aggressively.
How you can get the test done, it can be ordered in a blood test, separate from your regular cholesterol profile. But usually, you have to ask or bring up the discussion with your heart doctor. A lot of cardiologists don't check it individually or on their own independently, so asking them and bringing it up and making the conversation is helpful.
Prakash Chandran: Okay. So for myself, for example, my father had a cardiovascular event, I believe, when he was like 67. But his father, so my grandfather, died of a heart attack when he was 55. So obviously it's on my mind. I'm 40 years old and, you know, I do what most people do, which is go to their primary care physician probably once, maybe twice a year and get the blood work done. Is that where I would be getting this? Or do I have to ask for something in addition to going to my primary care provider?
Dr. Anthony Patrello: So there are some primary care doctors who are very savvy in terms of cardiovascular risk reduction and really are sub-specialists within epidemiology as well. And there are certainly some primary care doctors would be very comfortable in ordering this test. There's some who are comfortable in ordering it. And, if it's normal, then they're okay with it. And if it's abnormal, then refer to the cardiologist. And then there are some who say, "You know what? This is really out of the scope of what I'm comfortable doing. If you're really interested in getting a refined risk profile, you know, perhaps used to see a cardiologist." So I think it really depends on the comfort level of your own primary care doctor.
Prakash Chandran: Understood, but I think this is something that feels important enough for you to take control of, especially if you have some of the risk factors that you mentioned, wouldn't you say?
Dr. Anthony Patrello: I would absolutely agree with that. There's only a certain amount that the normal testing that we do can really tell us about your risk. And if we're really worried about your risk, for whatever reason and family history is usually the most common of those reasons, then really trying to refine that risk is really helpful. And this is one of the types of tests that can be helpful in that regard. So certainly, if it hasn't been brought up to you by your doctor, then bringing it up to your doctor would be the way to go.
Prakash Chandran: I've also heard about this notion of a proactive CT angiogram, I guess, measuring like certain calcification levels. Is this kind of the same or is that something that should be done coupled with this LP(a) test?
Dr. Anthony Patrello: That's an excellent question. So it's a different test, the CAT scan to look for calcium buildup in the arteries of the heart. That's looking for early evidence of atherosclerosis. I think if you're going to do that, and then you find that there is this elevated calcium score, elevated calcium buildup in the arteries, you probably don't also need the LP(a), because you've already identified somebody who is at a little bit of a higher risk and you've already stated that, "Okay, this is somebody who I'm going to treat more aggressively."
The time I would use the LP(a) is if you didn't want to get a CAT scan, which is a radiation exposure. It's not a high radiation exposure, but it's not a zero radiation exposure either. Or the calcium score was zero, which means that there's no elevated plaque yet, yet we still want to refine and we're still on the fence about whether or not the person should be treated with a cholesterol medicine aggressively to lower their cholesterol levels, that's where the LP(a) would come into play.
Prakash Chandran: Okay. That makes sense. So let's say you get the results back and your levels of LP(a) are a little bit high. What sorts of treatment options are available to you?
Dr. Anthony Patrello: So I think the reason why that most cardiologists or most doctors aren't checking it is because right now there's actually no great treatment for it. What it does tell us though is that this is a person who is at a higher risk overall. So basically, the treatment right now is just to address all of their risk factors more aggressively.
If they're overweight and you were kind of playing around with their weight a little bit, now you want to be really aggressive in trying to get their weight down. If their cholesterol has been kind of borderline and you've been on the fence about trying to lower that, this is somebody who you really want to lower it. And if you did want to lower it to lower than a hundred, perhaps you want to get to less than 70. If you want to get it less than 70, perhaps now you want to get it less than 40. So it's just going to augment what you're already doing for them.
There are some medications called PCSK9 inhibitors that can lower the LP(a) a little bit. The clinical significance of that is unclear. And there are clinical trials going on right now for dedicated treatment to lower LP(a) and those trials should be completed within next couple of years. And I think that's really going to move the needle in terms of risk reduction when those trials are completed and we have new therapeutics on the horizon.
Prakash Chandran: Okay. Well, that's good. You talked about doing all of the things that potentially lower your risk profile. One of them being potential diet and exercise. Do you have best practices for people around what they should be consuming and how often they should be exercising?
Dr. Anthony Patrello: Yes. So we should be exercising about 30 minutes a day, at least three days a week. And exercise is an activity that I would classify something that gets your heart rate elevated. So certainly, a slow walk in the neighborhood I think is good in terms of conditioning. But it's probably not really going to move the needle in terms of exercise. It's something that you really do want to get your heart rate elevated. Now, if you're so de-conditioned that that's what gets your heart rate elevated, then certainly that would count.
In terms of diet, there's certainly a ton of fad diets out there that people are using in order to lose weight. And there's tons of different ways to lose weight. But I think that the tried and true way in order to lose weight, keep weight off and do it in a healthy way without elevating your cholesterol levels, which some of the fad diets can, is using sort of a Mediterranean kind of a diet. You know, fruits, nuts, grains, vegetables, baked food, olive oil, nothing fried, minimizing dairies, minimizing carbs, minimizing pastas, and that kind of thing. And eating more of a well-balanced diet, monitoring portion control -- portion control is a major issue in this country -- trying to focus on those pillars.
Prakash Chandran: And is there anything that you can consume that will naturally help you lower this LP(a)?
Dr. Anthony Patrello: There is not. There is one medicine that has been used in the past called niacin. It's an old medicine that actually can lower LP(a) a little bit. But the problem is that it actually wasn't shown that lowering the LP(a) with niacin actually improved your event rate. So it didn't actually lower your risk of heart attack. And there's a ton of side effects that can happen with niacin. So that's not even recommended anymore. And so there's nothing really in the diet that can lower it. Really it tells you that you just want to lower your overall cholesterol even more aggressively because you have this risk factor.
Prakash Chandran: Okay. And one more thing I wanted to ask is how often should you be getting this LP(a) test?
Dr. Anthony Patrello: Right now, since there's no treatment for it that can lower your LP(a), I think it's a good one-time test to have. So I don't think it's something that we need to follow. If it's elevated, then we know that it's elevated and we know that that risk factor is there. Nothing that we're going to be doing is really going to be aimed at lowering that actual number. The whole goal of our treatment is going to be lowering your overall risk outside that number. So I think that really just a one-time check would be enough.
Prakash Chandran: Okay. And just as we close here, you've seen, I'm sure, so many patients throughout your career. If you had to share one piece of advice with them based on everything that you knew, what might that be?
Dr. Anthony Patrello: I think it goes back to the thing that you led with in the open is that, from an actuarial standpoint, your risk of dying from heart disease is greater than your risk of dying of anything else. And it's actually greater than the risk of you dying from the number two, number three, and then number four things on the list combined. So if you'd asked me statistically speaking, "How am I likely to die?" It's going to be probably from heart disease.
So if you would ask, "Well, what can I do to prolong my life?" Most likely, statistically speaking, you're most likely to die of heart disease, then your focus should be on trying to minimize your risk of heart disease. And I think taking it from that standpoint, I think gets people more motivated in trying to lead a healthier life.
Prakash Chandran: Well, Dr. Patrello, I think that is the perfect place to end. Thank you so much for your time today. We truly appreciate it.
That's Dr. Anthony Patrello, the Medical Director of Cardiovascular Services at Montefiore St. Louis Cornwall. For more information, head to MontefioreSLC.org. If you found this podcast helpful, please share it on your social channels and be sure to check out the entire podcast library for topics of interest to you.
Thanks for listening to this episode of Doc Talk. My name is Prakash Chandran, and we'll talk next time.