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Randomized Controlled Trial
. 2024 Apr 1;9(4):385-391.
doi: 10.1001/jamacardio.2023.5605.

Lipoprotein(a), C-Reactive Protein, and Cardiovascular Risk in Primary and Secondary Prevention Populations

Affiliations
Randomized Controlled Trial

Lipoprotein(a), C-Reactive Protein, and Cardiovascular Risk in Primary and Secondary Prevention Populations

Aeron M Small et al. JAMA Cardiol. .

Abstract

Importance: Elevated lipoprotein(a) (Lp[a]) is a putative causal risk factor for atherosclerotic cardiovascular disease (ASCVD). There are conflicting data as to whether Lp(a) may increase cardiovascular risk only in the presence of concomitant inflammation.

Objective: To investigate whether Lp(a) is associated with cardiovascular risk independent of high-sensitivity C-reactive protein (hs-CRP) in both primary and secondary prevention populations.

Design, setting, and participants: This cohort study uses data from 3 distinct cohorts, 1 population-based cohort and 2 randomized clinical trials. Participants included individuals from the UK Biobank (data from 2006-2010) without prevalent ASCVD, participants in the FOURIER (TIMI 59) trial (data from 2013-2017) who had baseline Lp(a) and hs-CRP data, and participants in the SAVOR-TIMI 53 trial (data from 2010-2013) who had prevalent ASCVD and baseline values for Lp(a) and hs-CRP. The data analysis took place from November 2022 to November 2023.

Exposure: Baseline plasma Lp(a), considered either as a continuous variable or dichotomized at 125 nmol/L.

Main outcomes and measures: Risk of major adverse cardiovascular events (MACE) (composite of cardiovascular death, myocardial infarction [MI], or ischemic stroke), the individual MACE components, and peripheral artery disease (PAD).

Results: Among 357 220 individuals in the UK Biobank without prevalent ASCVD, 232 699 (65%) had low hs-CRP (<2 mg/L), and 124 521 (35%) had high hs-CRP (≥2 mg/L) values. In a Cox proportional hazard model adjusted for ASCVD risk factors, higher Lp(a) was associated with increased cardiovascular risk regardless of baseline hs-CRP value for MACE (hs-CRP ≥2 mg/L: hazard ratio [HR] per 50-nmol/L higher Lp[a], 1.05; 95% CI, 1.04-1.07; P < .001; for hs-CRP <2 mg/L: HR, 1.05; 95% CI, 1.04-1.07; P < .001; P = .80 for interaction), as well as MI, ischemic stroke, and PAD individually. Among 34 020 individuals in the FOURIER and SAVOR trials with baseline cardiometabolic disease, there were 17 643 (52%) with low and 16 377 (48%) with high baseline hs-CRP values. In Cox proportional hazard models using aggregated data from FOURIER and SAVOR, higher baseline Lp(a) was associated with increased cardiovascular risk regardless of baseline hs-CRP for MACE (hs-CRP ≥2 mg/L: HR per 50-nmol/L higher Lp[a], 1.02; 95% CI, 1.00-1.05; P = .04; hs-CRP <2 mg/L: HR, 1.05; 95% CI, 1.02-1.08; P < .001; P = .16 for interaction), MI, and PAD.

Conclusions and relevance: In this study, higher levels of Lp(a) were associated with MACE, MI, and PAD in both primary and secondary prevention populations regardless of baseline hs-CRP value.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Scirica reported grants (institutional research support to Brigham and Women’s Hospital) from AstraZeneca and Eisai during the conduct of the study; grants (institutional research support to Brigham and Women’s Hospital) from Merck, Novo Nordisk, Better Therapeutics, Pfizer, Verve, Boehringer Ingelheim, and Amgen; serving on a data and safety monitoring board for Boehringer Ingelheim, AbbVie, AstraZeneca, Manmi, and Lexeo; consulting fees from Novo Nordisk; personal fees from Esperion; and equity from Health at Scale outside the submitted work. Dr Bhatt reported grants (research funding) from Sanofi and Regeneron during the conduct of the study; grants (research funding) from Amgen and Novartis outside the submitted work; and disclosed the following relationships: advisory board for Angiowave, Bayer, Boehringer Ingelheim, CellProthera, Cereno Scientific, Elsevier Practice Update Cardiology, High Enroll, Janssen, Level Ex, McKinsey, Medscape Cardiology, Merck, MyoKardia, NirvaMed, Novo Nordisk, PhaseBio, PLx Pharma, and Stasys; board of directors for American Heart Association (AHA); stock options or stock for Angiowave, Bristol Myers Squibb, DRS.LINQ, and High Enroll; consultant for Broadview Ventures, Hims, SFJ, and Youngene; data monitoring committees for Acesion Pharma, Assistance Publique-Hôpitaux de Paris, Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute, for the PORTICO trial, funded by St Jude Medical, now Abbott), Boston Scientific (chair, PEITHO trial), Cleveland Clinic, Contego Medical (chair, PERFORMANCE 2), Duke Clinical Research Institute, Mayo Clinic, Mount Sinai School of Medicine (for the ENVISAGE trial, funded by Daiichi Sankyo; for the ABILITY-DM trial, funded by Concept Medical; for ALLAY-HF, funded by Alleviant Medical), Novartis, Population Health Research Institute; Rutgers University (for the National Institutes of Health [NIH]-funded MINT Trial); honoraria from the American College of Cardiology (senior associate editor, Clinical Trials and News, ACC.org; chair, ACC Accreditation Oversight Committee), Arnold and Porter law firm (work related to Sanofi/Bristol-Myers Squibb clopidogrel litigation), Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute; RE-DUAL PCI clinical trial steering committee funded by Boehringer Ingelheim; AEGIS-II executive committee funded by CSL Behring), Belvoir Publications (editor in chief, Harvard Heart Letter), Canadian Medical and Surgical Knowledge Translation Research Group (clinical trial steering committees), CSL Behring (AHA lecture), Cowen and Company, Duke Clinical Research Institute (clinical trial steering committees, including for the PRONOUNCE trial, funded by Ferring Pharmaceuticals), HMP Global (editor in chief, Journal of Invasive Cardiology), Journal of the American College of Cardiology (guest editor, associate editor), K2P (co-chair, interdisciplinary curriculum), Level Ex, Medtelligence/ReachMD (CME steering committees), MJH Life Sciences, Oakstone CME (course director, Comprehensive Review of Interventional Cardiology), Piper Sandler, Population Health Research Institute (for the COMPASS operations committee, publications committee, steering committee, and US national co-leader, funded by Bayer), WebMD (CME steering committees), Wiley (steering committee), and Clinical Cardiology (Deputy Editor); being named on a patent for sotagliflozin (assigned to Brigham and Women’s Hospital who assigned to Lexicon; no income received from this patent); research funding from Abbott, Acesion Pharma, Afimmune, Aker Biomarine, Alnylam, Amarin, Amgen, AstraZeneca, Bayer, Beren, Boehringer Ingelheim, Boston Scientific, Bristol-Myers Squibb, Cardax, CellProthera, Cereno Scientific, Chiesi, CinCor, Cleerly, CSL Behring, Eisai, Ethicon, Faraday Pharmaceuticals, Ferring Pharmaceuticals, Forest Laboratories, Fractyl, Garmin, HLS Therapeutics, Idorsia, Ironwood, Ischemix, Janssen, Javelin, Lexicon, Lilly, Medtronic, Merck, Moderna, MyoKardia, NirvaMed, Novartis, Novo Nordisk, Otsuka, Owkin, Pfizer, PhaseBio, PLx Pharma, Recardio, Regeneron, Reid Hoffman Foundation, Roche, Sanofi, Stasys, Synaptic, The Medicines Company, Youngene, and 89Bio; royalties from Elsevier (editor, Braunwald’s Heart Disease); site co-investigator for Abbott, Biotronik, Boston Scientific, CSI, Endotronix, St. Jude Medical (now Abbott), Philips, SpectraWAVE, Svelte, and Vascular Solutions; trustee for American College of Cardiology; and unfunded research for FlowCo outside the submitted work. Dr Braunwald reported grants (through their institution) from AstraZeneca for the SAVOR trial and Bristol Myers Squibb for conduct of the SAVOR trial during the conduct of the study; grants (through their institution) from Daiichi Sankyo and Merck; consultant fees from Amgen, Myokardia (BMS), Boehringer Ingelheim/Lilly, Cardurion, and Verve outside the submitted work. Dr Giugliano reported grants from Amgen to Brigham and Women’s Hospital for clinical trials during the conduct of the study and lecture/CME fees from Amgen and Sanofi outside the submitted work. Dr Sabatine reported institutional research grants to the TIMI Study Group at Brigham and Women’s Hospital from Abbott, Amgen, Anthos Therapeutics, AstraZeneca, Boehringer Ingelheim, Daiichi-Sankyo, Eisai, Intarcia, IONIS, Merck, Novartis, Pfizer, Saghmos Therapeutics, and Verve Therapeutics and consulting fees from Anthos Therapeutics, AstraZeneca, Beren Therapeutics, Boehringer Ingelheim, Dr Reddy’s Laboratories, Fibrogen, Intarcia, Merck, Moderna, Novo Nordisk, Precision BioSciences, and Silence Therapeutics outside the submitted work. Dr Peloso reported grants from the NIH National Heart, Lung, and Blood Institute during the conduct of the study. Dr Marston reported grants from Ionis and Novartis and personal fees from Amgen, Beckman Coulter, and Viz.ai outside the submitted work. Dr Natarajan reported grants from Allelica, Apple, Amgen, Boston Scientific, Genentech/Roche, and Novartis; personal fees from Allelica, Apple, AstraZeneca, Blackstone Life Sciences, Creative Education Concepts, CRISPR Therapeutics, Eli Lilly & Co, Foresite Labs, Genentech/Roche, GV, HeartFlow, Magnet Biomedicine, Merck, Novartis, and Esperion Therapeutics; and other from Preciseli, MyOme, Ten Sixteen Bio, and Vertex Pharmaceuticals (spousal employment) outside the submitted work. No other disclosures were reported. Drs Melloni, Scirica, Braunwald, Giugliano, Sabatine, and Marston are members of the TIMI Study Group, which has also received institutional grant support through Brigham and Women’s Hospital from Abiomed, ARCA Biopharma, Janssen Research and Development, MedImmune, Regeneron Pharmaceuticals, Roche, Siemens Healthcare Diagnostics, Softcell Medical, The Medicines Company, and Zora Bioscience.

Figures

Figure 1.
Figure 1.. Hazard Ratios (HRs) of Cardiovascular Risk per 50-nmol/L Increase in Lipoprotein(a) by Strata of High-Sensitivity C-Reactive Protein (hs-CRP)
Hazard ratios for Cox-proportional hazards models of normalized lipoprotein(a) measurement and cardiovascular risk. Analyses are separated into strata with low (<2 mg/L) and high (≥2 mg/L) baseline hs-CRP for each cardiovascular outcome. Interaction P values are presented to test whether stratified effects were significantly different using continuous measurements of Lp(a) and hs-CRP. Interaction analyses in the UK Biobank (UKB) were performed using logistic regression and considering hs-CRP as a log-transformed variable.
Figure 2.
Figure 2.. Kaplan-Meier Curves Demonstrating Risk of Myocardial Infarction and Peripheral Artery Disease by Lipoprotein(a) (Lp[a]) and High-Sensitivity C-Reactive Protein (hs-CRP) in the TIMI Clinical Trials
Kaplan-Meier curves through median trial follow-up of 2.2 years demonstrating risk of myocardial infarction and peripheral artery disease using aggregated data from FOURIER and SAVOR clinical trials. Risk is subdivided into Lp(a) and hs-CRP categories. Absolute event rates and hazard ratios (HRs) are demonstrated by group.

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