Coronary Artery Calcium Scoring in the Context of Widespread Lipoprotein(a) Testing: Clinical Considerations and Implications for Lipid-Lowering Therapies

This review evaluates the interplay between lipoprotein(a) [Lp(a)] and coronary artery calcium (CAC) for risk prediction and preventive therapy selection, with a special emphasis on scenarios where these measures are discordant, particularly in otherwise intermediate-risk, primary prevention patients.

Observational studies and meta-analyses indicate a nuanced relationship between elevated Lp(a) levels and CAC burden and progression. Elevated Lp(a) is associated with an increased risk of CAC presence and progression; although, there is notable variability across studies. CAC predicts a similarly elevated risk in patients with low and high Lp(a). Joint elevation of Lp(a) and CAC is associated with a very high-risk patient subset.

Elevated Lp(a) should prompt consideration of CAC testing for further risk stratification. In the future, we anticipate that an elevated CAC score could prompt consideration of testing for Lp(a) in select patients, as identifying or confirming elevated Lp(a) may help guide the use of dedicated Lp(a)-lowering therapies in very high-risk primary prevention populations.