Lipoprotein(a) Lp(a): what is it, what are the risks, treatment, niacin, PCSK9, statins

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🩺ABOUT DR. BREWER
Dr. Brewer started as an Emergency Doctor. After seeing too many preventable heart attacks, he went to Johns Hopkins to learn Preventive Medicine. While there, he went on the run the post-graduate training program (residency) in Preventive Medicine. From there, he made a career of practicing and managing preventive medicine and primary care clinics. His later role in this area was Chief Medical Officer for Premise, which has close to 1,000 primary care/prevention clinics. He was also the Chief Medical Officer for MDLIVE, the second largest telemedicine company. More recently, he founded PrevMed, a heart attack, and stroke prevention clinic.

At PrevMed, we focus on heart attack, stroke, and cognitive decline. We serve patients who have already experienced an event as well as those who have not developed a diagnosis or event. Dr. Brewer provides services via telemedicine or in-person if you're in the Lexington, KY area. We find a lot of undiagnosed prediabetes or insulin resistance. Treating unrecognized risk factors like prediabetes allows reduction of risk and prevention of disease.

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[gl]

Hey Dr. I just found out that my Lp(a) levels were 796 mg/L.

The reason I got my levels checked is because I did a DNA consult and I had the gene LPA [2] - rs10455872.

What do you recommend other than Niacin?

[daffidavit]

I have normal HDL and LDL readings. But my LPa is over three times the upper limit. My dad had normal cholesterol levels too, yet all of his heart arteries were clogged by age 52. His brother died of a heart attack at age 48. Yet many of his other brothers and sisters (seven in all) lived into their mid 80s. When my dad was dying in the hospital from CAD with normal blood lipids, I asked his doctor to do a simple blood test for LPa. This was over 10 years ago. I knew that my LPa was 3 times the upper limit, but the doctor refused to do the blood test. That pissed me off because that would have given my family evidence that our CAD was caused by something other than low HDL or High LDL. I understand as of today 2.10.23 some drug companies are working on a drug to lower LPa, a major cause of CAD. I know this video is already 5 years old as I respond to it. I would hope that if anybody who recently has read this comment will give it a "thumbs up" not because I'm right or wrong, but because somebody has read it as of today 2.10.23 Thanks in advance.

[magsie]

Thank you sooo much for responding to my comment Dr Brewer. I was truly delighted that you took time for me.
I visit my GP this week so will insist on that chat and some tests because my heart was all over the place today. Thanks again because I would never have known if you didn't do what you do. You're so kind and generous.

[jaxxon]

My Lp(a) was 104 in 11/2018. In 06/2019 I had a coronary calcium score come back at 421. I eat plant based and would binge drink once or twice per month. I stopped the binge drinking, went as low carb as I can and cut out ALL processed foods (especially things with any kind of vegetable oil in the ingredients.) I started taking 500mg of Enduracin 3x per day, 2000mg Vitamin C 3x per day, 2000mg L-Proline 1x per day and 2000mg L-Lysine 3x per day (look up the Linus Pauling protocol.) I've only been doing all of this for 1 month and my latest Lp(a) test came back at 54 -- that's a nearly 50% reduction! Also, my total cholesterol has gone from 258 to 211, and my LDL has started coming down from 185 to 163 -- I've never been able to get these numbers to move before! I'm going to keep on this regimen and do another calcium score after the first of the year to hopefully see reduced or even reversed progress. Hope this is helpful to somebody!

[PrevMedHealth]

A comment by John Lorscheider (he's an avid, high-level cyclist and studies this topic a lot. I've not met many docs with his level of knowledge in this area. He provides some background on the Pauling/Rast "Unified theory". And, true to John's style, he's done some pretty good single-subject design research on himself in this area. [John, I'm curious to see the impact on that MACR as well. If you look it up, there has been research in this area. It's on my YT to-do list. There has been kidney improvement. But it takes years. )

There is a longstanding and still somewhat unproven theory that increases of plasma Lp(a) levels act as an acute-phase reactant. In other words, a person’s average Lp(a) level will rise, and sometimes sharply, in response to an acute injury to the endothelium of the artery wall. That response has been very well documented in people who have had myocardial infarctions and cardiovascular surgeries and shortly after their Lp(a) levels will spike.

That theory also proposes that the Lp(a) particles act as an healing agent to help repair the surgical site by sticking to the damaged arterial wall and patching the damage, if you will. So is Lp(a) our friend? And what about the millions of people who have high Lp(a) levels and have not had myocardial infarctions or cardiovascular surgery?

Perhaps arterial injury may mean arterial damage from diabetes, insulin resistance, sub-clinical chronic infection, oxidative damage, heavy metals, toxins, high blood pressure, homocysteine, just to name a few. Sustained elevated Lp(a) levels may indicate the underlying cause of the arterial damage has not been properly diagnosed and therefore remains inadequately treated.

Back in the ’80’s, Linus Pauling proposed that oxidative damage to the endothelium was a result of human’s lost ability to produce their own vitamin C, and that in turn initiated the atherosclerotic process. Hence, he proposed that high dose vitamin C, along with the amino acids lysine and proline, could protect the endothelium from oxidative damage which would in-turn result in a drop in Lp(a) levels. I tried that approach for 18 months and my Lp(a) levels never budged.

I’ve tracked my Lp(a) levels on an average of 3 times per year since 2009. I live a pretty clean life in terms of diet, exercise, BMI, blood pressure, fasting blood sugar, HbA1c, low stress and adequate sleep. I have seen my Lp(a) rise unexpectedly on three occasions to a maximum of 217 nmol/L and drop on two occasions to a low of 8.0 nmol/L. That’s a whopping 27-fold variation. My 9-year average Lp(a) level is 124 nmol/L. I’ve never been able to determine the cause for my variations. Maybe I am the cause of my Lp(a) and not my genetics. I have to wonder.

Getting a onetime Lp(a) level snapshot in a doctors office may tell us nothing. Doctors often say Lp(a) levels don’t change. I say nay!

I will be curious to see when, and if, my elevated MACR level drops from following a low carb diet and taking Metformin. If I see improvement in the "cracks in my tennis court" perhaps it may also have a beneficial effect on lower my Lp(a).

References:

Lp(a): an acute-phase reactant?


Relation between lipoprotein(a) concentrations in patients with acute-phase response and risk analysis for coronary heart disease



LIPOPROTEIN (a) AS AN ACUTE PHASE REACTANT IN PATIENTS ON CHRONIC HEMODIALYSIS



Transient changes of serum lipoprotein(a) as an acute phase protein

[magsie]

Thank you so much Dr Brewer, your videos are amazingly helpful. Im 64 and live in Australia. I've been finding it difficult to get my GP to get past just giving me a repeat script for lipitor without a chat. I havent understood why I'm taking it until watching you. I had a heart incident about 16 years ago that I think turned out to be gall stones. Dr just took out gall bladder without suggesting diet changes. I was very naive back then and didn't know to ask questions. About 5 years ago I had TIA. Recovered very well. Specialist said it was from a blind migraine so put me on lipitor and asprin. I weighed 65kg at the time. I'm now 61kg. I've changed my diet drastically...cut sugars and now eat more greens, butter, cream and eggs etc.
I have been getting cluster migraines lately and am concerned I might have another stroke. I've been trying for a long time to work out why I get migraines but no answers yet. Dr doesn't engage in conversation about it. I just take panadol to manage them.
I feel in good health and seem to have no heart problems except for irregular heart beat and flutters that I had 24 hr halter test for. It must've been ok because Dr didn't mention anything about it. Had no flutters during that 24hrs though.
I'm wondering if you might suggest something regarding the lipitor issue?

[jm-qjmx]

Thank you for your videos. They are very helpful & informative. I have a very high LP(a) level & I am starting the Linus Pauling protocol along with niacin. I am starting with 500 mg of niacin & will work by week to get to 2 grams. I have 2 questions for you: #1. Is it less beneficial to take niacin that is not extended release? I chose not to take extended release for fear of liver problems. It’s still just plain niacin, though. #2. Do you know how close we are to getting antisense inhibition therapy or any other medications? How close are these drugs to FDA approval? All the studies I read showed they had serious side effects & the studies that showed no side effects were funded by the pharmaceutical company making the drug. Thanks again. I will be getting another lipid panel in 6 months to see if there is any improvement.

[AgrippaMaxentius]

Hey Doc. My LPa is 288. I’m 35 and have non obstructive coronary disease of 3 vessels. 30-40%. To say I am terrified is an understatement and I have daily anxiety revolving around it. Things I have done to improve or mitigate other factors are. I stopped smoking, I started taking Rosuvastatin which has lowered my bad ldl from 166 to 53. I’ve lost a lot of weight, have been keeping my blood pressure in check. Have been doing daily 1 hour walks with some jogging and sometimes even longer. You and Dr Attia mention that mitigating those other risk factors can help avoiding issues with the high LPA, is that true? I’m literally crying typing this just from the stress, afraid to do anything in my life at all.

[pumacorp]

Doc whats your thoughts on PSCK9 inhibitors ???My Doc keeps pushing them on me as he is a very unorthodox Dr and is not afraid to think outside the box .My Dr is not big on statins at all....He has tried repatha on my uncle who had a 98% blockage in his corroded artery ..He gave him this swearing it would reverse and clear the clog ., but still sent him to the vascular surgeon ..Well he went to a vascular surgeon and they scanned him twice as he blockage is gone .. So do you think this is just a coincidence or what cause he has me really wondering with these results ..My Doc runs everything by me about my uncle cause my uncle is his own worst enemy and knows Ill stay on top of him..I am shocked as I have seen the results myself ..Whats your opinion on this ?Also the other side of the coin he had a 98% blockage in is heart well after repatha so its kind of a slap in the face in one aspect but a huge success in the other ..

[westfield]

I think the field of cardiology has gotten a self sustained black eye over the last decade due to widely announced proclamations of game changers but they never materialized. The stem cells were supposed to end heart cell damage. But as we saw those went nowhere and most of these companies folded silently. Then you had the big press of apo 1 Milano gene and once again nothing came out of that except hype. Then you had the dissolvable stents and those flunked out. Then you had high levels of niacin and that was found to be dangerous and trials were stopped. Then you had PCSK9 and everyone proclaimed we would never have heart disease again but that came and still nothing happened. Now it’s LP little a. I think cardiology needs to regroup. Less hypes and instead focus on science and it’s time we get a big game changer in this field. It’s way overdue.

[halsvk]

I have elevated Lp(a) and considering taking extra Niacin. But I am concerned of my high HDL (over 2.2 mmol/L; range is 1-2) which Niacin can elevate even higher.

[darwinhughey]

I've had 3 stents and 3 way bypass 60 years old, non smoker, low cholesterol . Lipo a 237... Currently in stage 3 clinical trials. Should have a cure in 4 years! Get your lipo a checked!

[chadthomas]

HI Dr. Brewer, I need your advice. I am 33 years old and I just had my LPA - Lipoprotein (a) tested and it was 2032 mg/L.

My general practitioner did not offer much information. Can you please offer me some advice. I know this is a high amount, and I am worried sick about how severe this is.

He put me on Aspirin 81 and a low dose cholesterol med and said he will test it my next year at my physical.

Thank you so much for taking a moment to help. Chad

[gcam]

Thank you very much for ALL your stellar work and immensely helpful videos. Question: What are your feelings about NMN or NR to affect LP(a) instead of Niacin? Chris Masterjohn has put our a video warning of using too high a dose of NR. So my proposed NR dose would be less than 50mg / day, not the commonly available 200+ mg capsules.
Thank you again!

[StacySteMarie]

Hey Doc, I heard that AMLA can lower Lpa. Do you have any information about this?

[beepbeepnj]

How is it possible that Lipoprotein (a) is bad when there are articles on Pubmed that say Centenarians have elevated levels of Lp(a)
that could be in the genetics for a good reason as to be protective for the body? Please explain.

[erharddinges]

Thank you! Sounds promising! Hope it is not too late for me! I am 67 and already had a little stroke.My Lp-a was about 100 and nobody had any idea how to treat.

[allenlee]

is it an autosomal dominant trait, an autosomal recessive trait, or an X-linked recessive trait? What is the gene affected? Where is this gene located?
I'm very intrested because my father has it and is a carrier

[justrusty]

I have generally had "high" cholesterol, even when I first got out of college (I had been an athlete and expected it to be low, but it wasn't), and it's been up and down since then, as high as 280, as low as 202 (untreated with statins.) Statins did lower this substantially but I was susceptible to side effects, and had to get off them. My doctor ordered an Lp(a) test and my level is 7. Obviously you can't offer specific advice, but can you comment generally on what other markers could be of concern? It seems Lp(a) in and of itself is not a problem for me, if I understand this right. Also CRP = 0.5, but I have a family history of CVD; brothers, father, paternal grandfather, etc.)

[haidersyed]

Do you suggest l-lysine for heart health?