ABSTRACT
Lipoprotein(a) is an apolipoprotein B100-containing low-density lipoprotein-like particle that is rich in cholesterol, and is associated with a second major protein, apolipoprotein(a). Apolipoprotein(a) possesses structural similarity to plasminogen but lacks fibrinolytic activity. As a consequence of its composite structure, lipoprotein(a) may: (1) elicit a prothrombotic/antifibrinolytic action favouring clot stability; and (2) enhance atherosclerosis progression via its propensity for retention in the arterial intima, with deposition of its cholesterol load at sites of plaque formation. Equally, lipoprotein(a) may induce inflammation and calcification in the aortic leaflet valve interstitium, leading to calcific aortic valve stenosis. Experimental, epidemiological and genetic evidence support the contention that elevated concentrations of lipoprotein(a) are causally related to atherothrombotic risk and equally to calcific aortic valve stenosis. The plasma concentration of lipoprotein(a) is principally determined by genetic factors, is not influenced by dietary habits, remains essentially constant over the lifetime of a given individual and is the most powerful variable for prediction of lipoprotein(a)-associated cardiovascular risk. However, major interindividual variations (up to 1000-fold) are characteristic of lipoprotein(a) concentrations. In this context, lipoprotein(a) assays, although currently insufficiently standardized, are of considerable interest, not only in stratifying cardiovascular risk, but equally in the clinical follow-up of patients treated with novel lipid-lowering therapies targeted at lipoprotein(a) (e.g. antiapolipoprotein(a) antisense oligonucleotides and small interfering ribonucleic acids) that markedly reduce circulating lipoprotein(a) concentrations. We recommend that lipoprotein(a) be measured once in subjects at high cardiovascular risk with premature coronary heart disease, in familial hypercholesterolaemia, in those with a family history of coronary heart disease and in those with recurrent coronary heart disease despite lipid-lowering treatment. Because of its clinical relevance, the cost of lipoprotein(a) testing should be covered by social security and health authorities.
Subject(s)
Atherosclerosis , Cardiovascular Diseases , Cardiovascular Diseases/diagnosis , Cardiovascular Diseases/epidemiology , Consensus , Humans , Lipoprotein(a) , Risk FactorsABSTRACT
Should we prescribe statins for primary prevention of cardiovascular risk ? About half of cardiovascular events occur among people in primary prevention. Recently, 2 well-conducted meta-analyses of randomized clinical trials demonstrated that primary prevention with statin treatment leads to a 14% decrease of all-cause mortality and to a 22-27% decrease of major cardiovascular events. The cost-effectiveness ratio of primary prevention with statins is largely positive because the number of patients needed to treat during 5 years to prevent one major cardiovascular event is low (less than 100). The cardiovascular benefit of primary prevention with statins exceeds the risk of potential adverse events. The challenge of primary prevention is to identify high cardiovascular risk patients in whom a statin treatment will prevent a major cardiovascular event.
Faut-il prescrire des statines en prévention primaire du risque cardiovasculaire ? La moitié des événements cardiovasculaires surviennent chez des patients en prévention primaire. Récemment, deux méta-analyses très bien conduites et regroupant les résultats d'essais cliniques randomisés viennent de démontrer que le traitement par statines en prévention primaire permet de diminuer la mortalité toutes causes de 14 % et les événements cardiovasculaires majeurs de 22 à 27 %. Le rapport coût-bénéfice du traitement par statines en prévention primaire est largement positif car le nombre de patients à traiter pendant 5 ans pour éviter un événement est faible (inférieur à 100). Ce bénéfice cardiovasculaire reste largement supérieur au risque potentiel d'effets indésirables. Tout l'enjeu de la prévention primaire réside dans l'identification éclairée des patients à haut risque cardiovasculaire chez lesquels un traitement par statines permettra d'éviter un événement cardiovasculaire majeur.
