Lipoprotein(a) is an established risk factor for atherosclerotic cardiovascular disease (ASCVD), with strong evidence of causality from genetic and epidemiological studies. This recognition has led to the development of multiple potent lipoprotein(a)-lowering therapies, four of which are currently in phase 3 cardiovascular outcomes trials. Despite this progress, several critical knowledge gaps remain. Notably, the potential role of high lipoprotein(a) in non-coronary vascular diseases, specifically peripheral arterial disease, major adverse limb events, and abdominal aortic aneurysms, has not been adequately investigated, despite the considerable morbidity and mortality associated with these conditions. Furthermore, recent findings suggest that systemic low-grade inflammation, as measured by high-sensitivity C-reactive protein (hsCRP), may modify the ASCVD risk attributable to high lipoprotein(a). This raises the possibility that future lipoprotein(a)-lowering therapies may only benefit individuals with concomitantly elevated hsCRP. This review summarizes the current knowledge of lipoprotein(a) as a risk factor for cardiovascular disease and aortic valve stenosis, outlines the emerging evidence linking lipoprotein(a) with peripheral arterial disease, major adverse limb events, and abdominal aortic aneurysms, and examines whether high lipoprotein(a) independently predicts the risk of ASCVD and aortic valve stenosis regardless of the presence or absence of systemic low-grade inflammation. By placing recent studies within a broader scientific landscape, we will thus attempt to clarify the vascular relevance of high lipoprotein(a) beyond coronary disease and inform precision targeting of future lipoprotein(a)-lowering therapies.

Current Lp(a)-related scientific literature is mainly related to cardiovascular diseases, while less attention has been paid to the role of Lp(a) in both the severity of infections and the vascular disease events that follow them. In this perspective article, we highlight findings related to lipoprotein(a) [Lp(a)] in infectious diseases, including those caused by the severe acute respiratory syndrome coronavirus 2, human immunodeficiency virus, hepatitis C virus (HCV), Helicobacter pylori, Chlamydia pneumoniae, cytomegalovirus, or the Plasmodium and trypanosomal parasites. Based on the data from the above-mentioned infections and Lp(a), the role of Lp(a) in these common infectious diseases will be discussed. Of particular interest is that Lp(a) can inhibit HCV infection and is also important for protection against parasitic infections such as malaria and trypanosomiasis. New drugs, like muvalaplin, significantly lower Lp(a) levels, and it is therefore important to learn about the significance of low Lp(a) levels in terms of the potential course of an infection. It remains to be seen whether Lp(a) drugs with different mechanisms of action are relevant for infections.

Aims: Elevated lipoprotein(a) [Lp(a)] is an overlooked and underdiagnosed risk factor for peripheral artery disease (PAD). Negligible testing rates of Lp(a) in patients with PAD are suspected to be largely caused by implementation barriers and poor awareness. Here, we report pilot results of the newly initiated Lp(a)-PAD inpatient care pathway that employs the LILAC-for-Lp(a) framework.

Methods: A review of the process of implementation of the inpatient Lp(a)-PAD pathway was undertaken using quality improvement methods. The prevalence of elevated Lp(a), and its association with the severity of chronic limb ischaemia were investigated.

Results: At 3 months after integrating detection of Lp(a) in the care of patients admitted to hospital for PAD-related limb ischaemia issues, 22.6% of the 106 patients were detected to have elevated Lp(a) levels ≥ 120 nmol/L, and 34.9% with mildly raised Lp(a) ≥ 70 nmol/L. There was a higher proportion of patients with levels ≥ 120 nmol/L compared with Lp(a) < 120 nmol/L who had category 6 classification of chronic limb ischaemia by Rutherford classification (95.8% vs 70.7%, p-value = 0.011). Lp(a) ≥ 120 nmol/L and Lp(a) as a continuous variable were associated with the highest severity of limb ischaemia, p = 0.032 and p = 0.045, respectively. The low-density lipoprotein (LDL) attainment goal in our patients with PAD was suboptimal; LDL-C < 1.4 mmol/L goal attainment was achieved in 30.2% of all patients and 25.0% of the group of elevated Lp(a), respectively.

Conclusion: This pilot study suggests that the LILAC-for-Lp(a) framework, via multidisciplinary collaboration and quality improvement methods, is helpful to integrate Lp(a) testing into PAD management.