Nathan Wong, PhD, MPH after yet another study highlighted Lp(a)’s cardiovascular risks, including among patients without ASCVD.

Preventive Cardiology

Lipoprotein(a)’s High (and Uneven) Cardiovascular Risks

Harvard researchers strengthened the link between high Lipoprotein(a) levels and greater risks of future cardiovascular events, including among patients who haven’t been diagnosed with ASCVD.

The researchers analyzed 12-year outcomes from 16,419 people in the Mass General Brigham Lp(a) Registry who had their Lp(a) measured between 2000 to 2019, including 62% with a history of ASCVD (prior MI, revascularization, ischemic stroke).

Patients with ASCVD histories generally had higher Lp(a) levels than those without ASCVD (37.8 vs 31.1 nmol/L), but Lp(a)’s future MACE risks increased at a far steeper rate among the patients without ASCVD. 

Compared to patients in the 1st to 50th percentile of Lp(a) levels, patients in the…

• 51st to 70th Lp(a) percentiles had a 14% greater MACE risk if they also had ASCVD, and a 9% greater MACE risk if they didn’t have ASCVD.
• 71st to 90th Lp(a) percentiles had a 21% greater MACE risk if they also had ASCVD, and a 17% greater MACE risk if they didn’t have ASCVD.
• 91st to 100th Lp(a) percentiles had a 26% greater MACE risk if they also had ASCVD, and a 93% greater MACE risk if they didn’t have ASCVD.

Annual MACE rates were still highest among the patients with ASCVD compared to those without ASCVD across the four Lp(a) percentile levels (annual MACE rates: 4.1%, 4.9%, 5.3%, 5.3% vs. 1.1%, 1.2%, 1.3%, and 2.2%).

• However, the ASCVD patients’ saw their risk plateau beyond the 70th percentile, while the non-ASCVD patients’ risk significantly increased at the 90th Lp(a) percentile.

Those differences in Lp(a) risk thresholds could have a significant impact on patient screening decisions and patient selection for future Lp(a) trials, especially considering that many patients with high Lp(a) levels wouldn’t be included in the current Lp(a) Phase 3 trials.

The Takeaway

Using real world data, this study further confirms conclusions from previous Lp(a) studies, while revealing that Lp(a)-related MACE risk thresholds can be quite different among primary and secondary prevention patients. That could have a big influence on future trials, which could in turn have a big influence on future Lp(a) testing and treatment guidelines.

Unify Your Cardiovascular Data

In this era of interoperability, it’s time to focus on cardiology. See how Change Healthcare’s enterprise cardiology platform provides a single database for CPACS, Hemo, CVIS, and ECGM — helping to improve data access and integrity while simplifying your IT configuration.

Relying on Echo AI for Heart Failure Management

The ESC has updated its heart failure guidelines, for the first time including a guideline-directed medical therapy for heart failure with preserved ejection fraction (HFpEF). See how cardiologists are trusting echo AI to find these cases earlier in this video from Us2.ai.

Can AI Improve How We Prevent Heart Disease Progression?

Tune in to Cleerly’s upcoming webinar (March 19, 2pm ET) where study leaders will discuss how the landmark TRANSFORM randomized controlled trial will test whether an AI-personalized care strategy can outperform traditional risk factor management and prevent cardiovascular events.

The Wire

• Intravascular Imaging’s PCI Risk Reductions: In a Lancet meta-analysis, intravascular imaging-guided PCI procedures were found to significantly reduce major adverse event risks compared to conventional angiography guidance. Among 15,964 patients from 22 trials, OCT or ultrasound-guided PCI drove remarkable decreases in target lesion failure (-29%), cardiac death (-45%), all-cause death (-25%), and heart attacks (-17%).

• Argá’s PFA Funding: The pulsed field ablation segment’s momentum continued this week with Argá Medtech’s €54M Series B round. Argá will use the new funding to support US and EU studies evaluating its Coherent Sine-Burst Electroporation cardiac ablation system, and expand its US operations. The PFA segment has seen a “pulse” of activity in recent months, including Medtronic and Boston Scientific’s FDA approvals, increased PFA momentum from Abbott and Biosense Webster, and new funding for other PFA startups like Field Medical. 

• FFR AI Smooths TAVR Workup: AI-based fractional flow reserve predictions (FFRai) based on photon counting CT coronary angiography (PC-CCTA) exams could improve TAVR workups. In a study of 260 patients, FFRai (using Spimed’s CorEx solution) produced stenosis quantifications with far greater AUCs than PC-CCTA alone (0.92 vs. 0.82), while FFRai could have prevented invasive coronary angiography in 46.5% of cases (vs. 37.3% w/ PC-CCTA alone).

• VahatiCor’s First A-FLUX Treatment: VahatiCor announced the first use of its A-FLUX Reducer, an implant that’s placed in the coronary sinus to increase blood flow to the ischemic portion of the heart, improving symptoms and quality of life in patients with angina or chest pain. The patient received the first A-FLUX Reducer implant through Health Canada’s Special Access Program, while VahatiCor will begin enrollment for A-FLUX’s multi-center clinical study later this year.

• No Stress (Tests) POST-PCI: The POST-PCI trial revealed that routine stress tests don’t bring extra benefits to patients after high-risk multivessel or left main coronary interventions. There was no significant difference in the study’s primary composite outcome (death, MI, or hospitalization for unstable angina at 2 years) between patients getting routine functional stress testing and those receiving standard care alone (6.2% vs. 5.7%, p=0.85). Interestingly, routine stress testing was associated with increased rates of invasive angiography and repeat revascularization beyond 1 year.

• Did Medicare Mandate Dampen ICD Use? A new JAMA paper suggests that a 2018 Medicare shared decision-making mandate regarding the use of ICDs for primary prevention of cardiac events did not hurt ICD adoption. In the study of Medicare files between 2016 and 2020, primary prevention ICD use decreased at a monthly rate of 2.37 procedures per 100k beneficiaries before the mandate, and declined by just 0.77 procedures per 100k beneficiaries per month after the mandate.

• Signify Adds In-Home AFib Testing: CVS’s value-based care subsidiary Signify Health announced the addition of arrhythmia testing to its in-home Diagnostic and Preventive Services offering. Signify will screen patients to identify those with greater arrhythmia risks, and offer ECG patches to all at-risk patients without contraindications. After 14 days of continuous wear, ECG data will be shared with a cardiologist for AFib diagnosis, and those findings will then be shared with members and their PCPs. Signify’s new home AFib testing service comes about 5 months after it added home kidney health evaluations.

• PCSK9i’s Adoption Challenges: Despite label expansions and price reductions, the use of PCSK9 inhibitors to combat ASCVD has faced an uphill battle. Between 2019-2021, 31% of initial PCSK9i prescriptions were declined by insurers, and less than 50% of prescriptions were “paid” (covered by insurer and retrieved by patient), lagging far behind other branded cardiometabolic drugs. 

• Ultra-Processed Food and CV Events: A meta-analysis of 20 studies and about 1.1 million people highlighted the negative cardiovascular effects of ultra-processed food (UPF). In the analysis, an additional daily serving of UPF brought a 2.2% higher risk for CV events, while a 10% increase in UPF consumption resulted in a 1.9% increased CV event risk. However, the analysis didn’t reveal a link between UPFs and cerebrovascular events.

• Bypass Price Variations: The price of CABG procedures across the US vary widely, with commercial rates well above Medicare. That’s from a study of 544 US hospitals that found that median commercial and self-pay CAGB prices were over two-times Medicare rates ($57k & $75k vs. $28k). The study also revealed wide regional variations, particularly comparing median hospital prices in the East South Central and Pacific regions ($35k vs. $84k). However, variations don’t appear to align with quality of care, including death, readmissions, or CMS hospital ratings.

• FFRCT’s Low-CAC Superiority: A new meta-analysis found that FFRCT is superior to CCTA for detecting hemodynamic stenoses in patients with sub-400 coronary calcium scores. Among patients with <400 CAC scores, FFRCT detected hemodynamic stenoses with a 0.9 per patient AUC and a 0.8 per vessel AUC (vs. 0.74 w/ CCT), while FFRC’s advantage was even stronger among patients with <100 CAC scores (AUCs: 0.9 & 0.92 vs. 0.32 & 0.66).

The Benefits of Outsourced Post-Processing

Using an outsourced cardiac image post-processing solution doesn’t have to mean sacrificing control of the results. Discover how PIA’s customizable post-processing workflow can help you get the most out of your images.

Where to Go for Cardio AI?

TeraRecon’s Cardio Suite is a collection of hand-selected, vendor-neutral Cardiology AI algorithms that aid in the analysis and interpretation of echocardiograms and chest CTs. Learn about TeraRecon’s AI offering and how they improve efficiency and accuracy here.

The Resource Wire

• Experience the future of learning: Medtronic Academy 2.0 is here! Unlock your ultimate destination for structural heart medical education with the newly redesigned Medtronic Academy 2.0. Gain access to expert-led courses, webinars, and a wealth of resources to stay ahead in cardiovascular care. Visit now!

• From CPACS to CVIS: Cardiovascular imaging has come a long way from CPACS. Explore the evolution of cardiology image and data management in this Merge by Merative executive brief, and see what makes CVIS such a significant advancement.

• The First Step to Coronary Artery Disease Diagnosis: HeartFlow’s new RoadMap Analysis solution allows CT readers to accurately, efficiently, and consistently identify stenoses in the coronary arteries. See how RoadMap Analysis’ visual and quantitative insights into the narrowing of all major coronary arteries helps readers evaluate coronary CT angiograms before determining the need for an FFRCT.

• AHA Honors Stanford & Bunkerhill’s Incidental CAC Paper: Stanford University’s paper exploring how Bunkerhill’s incidental CAC algorithm increased statin use won the American Heart Association’s 2023 Willerson Award for the best clinical paper published in Circulation this year. See how Bunkerhill’s incidental CAC impacted patient care here.

• Automatic, Precise Analysis – From the First Beat: Monebo’s Kinetic ECG Algorithm leads with its versatility, precision, and efficiency, enabling a long list of use cases. See how it might impact your ECG monitoring clients here.