Many years ago when my children were around 6 months and under 2, I came back home late one night to our London flat after a friend’s leaving party to hear my daughter crying and crying. Wondering why my wife hadn’t gone to her, I soon discovered the answer was that she couldn’t, because she was doubled up in pain in the bathroom unable to move. My wife is rather stoic (a couple of paracetamol, gas and air got her through both baby’s deliveries) so to find her like this I knew something was pretty wrong. I called 999 for an ambulance, but was told she didn’t sound ill enough to warrant going to hospital and we should try a GP in the morning! I tried to point out the fact that was a senior registrar, and knew she needed hospital treatment, but it fell on deaf ears. I couldn’t drive as was over the alcohol limit, and anyway we had no-one nearby to look after the babies, so ended up muddling through the night, then driving her to University College London A and E the next morning. She was clearly very unwell, and her blood tests came back showing a major issue with her liver. It turned out she had a gallstone stuck, and needed an emergency procedure to relieve the blockage. I never have quite forgiven the 999 call handler.
I mention this story, as it came to mind this week when I saw a lady in her 30s, with a fairly new baby by her side, in hospital with chest pain. Looking at the notes, I was surprised to read she had been in recently with a heart attack. In a lady of this age, heart attacks are of course pretty rare. Sometimes they can be caused by something called SCAD (spontaneous coronary artery dissection – a tear in the lining of a heart artery), the use of cocaine and some other illicit drugs, but neither of those things applied in her case.
Ok then, I thought, she must have some other issue – high blood pressure, obesity, diabetes, smoking, raised cholesterol, a family history of heart attacks…..
Nope.
She had bona fide coronary disease, had needed a stent to be implanted, yet no risk factors for heart disease. What could be going on?
I don’t have an answer as yet, but I do have a plan, which is to check an advanced lipid profile (think of this like a cholesterol check you might get at your GP, with a bunch of other more sophisticated blood tests to give a better overall picture of your heart risk) and a test called Lipoprotein (a). By coincidence, I was playing a few holes of golf on friday evening with a GP friend of mine, whose brother has coronary disease, had been reading online and asked him if he needed to get his Lipoprotein (a) checked. My GP friend wasn’t sure what to advise hence asking me, and I suspect many GPs are unaware of what it is. I’ve written about this before, but over a year ago, and thought worth a re-fresh given this week’s events.
Lp (a) (as it is known for short) is a marker of increased risk of cardiovascular disease. Importantly however, it is genetically inherited. Having a raised Lp (a) increases the risk of a heart attack or stroke, and the magnitude of that increased risk varies whether a person does or does not already have heart disease.
To put it another way, if a person does not have any heart issue, this blood test can really add additional important information to their risk assessment. If they do have heart disease, AND a raised Lp (a) we should be even more aggressive with risk factor modification. European guidelines do recommend that everyone gets it checked, and hopefully in time that will be the case, but at the current time I’m not aware of any country in the world that does so. It’s not necessarily a test that needs repeating (due to the nature of it being inherited). If you would like your Lp (a) checked, hit reply and Sarah can get you booked in. The test costs around £100 including phlebotomy. If you want the full advanced lipid profile checked, which also includes Apolipoprotein levels, and measures of inflammation, this is around £350. That compares fairly well to the cost of servicing a car!
All very interesting you might say, but what can we actually do about it? Although drugs are in development to treat Lp (a), we don’t actually have a treatment yet. However, what we do have, is the ability to make individualised assessments of risk. We also know that patients who have higher Lp (a) levels do better if they have lower LDL and lower blood pressure. There is also a debate to be had about the use of low dose aspirin, which in my view very much depends on a careful risk assessment of a person’s heart attack and stroke risk on one hand, and bleeding risk on the other. These days we have a great many options to treat lipid levels, so even if we can’t treat Lp (a) yet, it is certainly possible to lower risk in other ways with other medications if needed.
Back to the young lady I saw, and time will tell on her test results, but in the meantime thankfully nothing major had happened this time. It’s very common after a heart attack for patients to be anxious, and this may well have played a role in needing to come back to hospital. My heart really went out to her though, and I told her my own personal story of my wife’s problems all those years ago. Sometimes as a doctor we don’t have all the answers, but listening and empathy can often go a long way.