Methodological and clinical considerations regarding lipoprotein(a) risk assessment in secondary prevention

We read with great interest the article ‘Lipoprotein(a), atherosclerotic plaque burden, and long-term cardiovascular outcomes in patients with coronary artery disease1’ by de Mira et al. The authors reported that in patients with established cardiovascular disease, elevated Lp(a) (>125 nmol/L) was associated with a greater intravascular ultrasound (IVUS)-derived atherosclerotic plaque burden, yet it did not predict an increased incidence of 5-year major adverse cardiac events (MACE) or 10-year all-cause mortality. The investigators hypothesize that in a secondary prevention setting where aggressive cholesterol-lowering therapy is implemented, the incremental near-term risk conferred by Lp(a) may be mitigated. While we commend the authors for leveraging a robust imaging cohort, translating these findings into contemporary clinical practice requires cautious interpretation. From a clinical management perspective, we believe the study’s conclusion regarding the lack of prognostic utility for Lp(a) may inadvertently convey a false sense of security, driven by two critical nuances in modern lipidology and disease trajectory.