Abstract

Case Report

Recurrent Cardiac Events Driven by Prothrombotic Burden in a Patient Undergoing Lipoprotein Apheresis for High Lp(a) Levels

Gabriele Cioni*, Rossella Marcucci, Rosanna Abbate and Giovanna D’Alessandri

Published: 15 March, 2017 | Volume 1 - Issue 1 | Pages: 001-005

Introduction: Lipoprotein (a) [Lp(a)] is a marker for cardiovascular disease, involved in pathogenesis and progression of atherosclerosis. In selected high-risk patients, lipoprotein-apheresis could optimize secondary prevention and improve prognosis.

Aim: We presented the case of a 49-year-old man with high lipoprotein (a) levels and recurrent cardiac adverse events, despite maximal pharmacological therapy.

Case report: Four years before the admission at our Centre, he presented an anterior STEMI, treated with angioplasty and implantation of a drug eluting stent on left anterior descending artery, at the age of 47 years, in September 2012; one month later, the patients presented a new episode of angina, and exams showed a critical stenosis in the right coronary artery, treated by angioplasty and implantation of drug eluting stent. Because of high Lp(a) plasma levels, patient was subsequently on regularly 7-10 day lipoprotein apheresis.

Results and discussion: A thrombophilic screening was performed, showing the simultaneous presence of heterozygous V Leiden mutation and prothrombin G20210A mutation. He referred to our Centre in order to optimize therapy; we performed an endothelial function assessment showing a severe dysfunctional pattern.

Because of these findings, we prescribed dual antiplatelet therapy, and we added omega-3 fatty acids and association with nicotinic acid/laropiprant. According with current guidelines, considering the high risk of bleeding, we preferred not to administer anticoagulant therapy. At 6-month and 1-year follow up the patient continued lipoprotein apheresis and was asymptomatic for other cardiovascular events.

Conclusions: The assessment for the eventual presence of thrombophilia might become a useful tool in clinical practice for high-risk selected patients.

Read Full Article HTML DOI: 10.29328/journal.hcem.1001001 Cite this Article Read Full Article PDF

Keywords:

Lipoprotein apheresis; Thrombophilia lipoprotein; (a)Endothelial dysfunction peripheral arterial tonometry TEXT

References

  1. Anuurad E, Boffa MB, Koschinsky ML, Berglund L. Lipoprotein(a): a unique risk factor for cardiovascular disease. Clin Lab Med. 2006; 26: 751-772. Ref.: https://goo.gl/Q8XV9Z
  2. Boffa MB, Marcovina SM, Koschinsky ML. Lipoprotein(a) as a risk factor for atherosclerosis and thrombosis: mechanistic insights from animal models. Clin Biochem. 2004; 37: 333-343. Ref.: https://goo.gl/Dm0jv3
  3. Danesh J, Erqou S. Risk factors: Lipoprotein(a) and coronary disease-moving closer to causality. Nat Rev Cardiol. 2009; 6: 565-567. Ref.: https://goo.gl/fYG7J0
  4. Emerging Risk Factors Collaboration, Erqou S, Kaptoge S, Perry PL, Di Angelantonio E, et al. Lipoprotein(a) concentration and the risk of coronary heart disease, stroke, and nonvascular mortality. JAMA. 2009; 302: 412-423. Ref.: https://goo.gl/6XVYRI
  5. Sofi F, Marcucci R, Abbate R, Gensini GF, Prisco D. Lipoprotein (a) and venous thromboembolism in adults: a meta-analysis. Am J Med. 2007; 120: 728-733. Ref.: https://goo.gl/6sJAkk
  6. Klingel R, Heibges A, Fassbender C. Lipoprotein apheresis results in plaque stabilization and prevention of cardiovascular events: comments on the prospective Pro(a)LiFe study. Clin Res Cardiol Suppl. 2015; 10: 46-50. Ref.: https://goo.gl/pJcLcy
  7. Archontakis S, Pottle A, Hakim N, Ilsley C, Barbir M. LDL-apheresis: indications and clinical experience in a tertiary cardiac centre. Int J Clin Pract. 2007; 61: 1834-1842. Ref.: https://goo.gl/w1IKOa
  8. European Stroke Organisation, Tendera M, Aboyans V, Bartelink ML, Baumgartner I, et al. ESC Guidelines on the diagnosis and treatment of peripheral artery diseases: Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries: the Task Force on the Diagnosis and Treatment of Peripheral Artery Diseases of the European Society of Cardiology (ESC). Eur Heart J. 2011; 32: 2851-2906. Ref.: https://goo.gl/8FSRsz
  9. Schwartz J, Padmanabhan A, Aqui N, Balogun RA, Connelly-Smith L, et al. Guidelines on the Use of Therapeutic Apheresis in Clinical Practice-EvidenceBased Approach from the Writing Committee of the American Society for Apheresis: The Seventh Special Issue. J Clin Apher.2016; 31: 149-162. Ref.: https://goo.gl/L5bl54
  10. The HPS-THRIVE Collaborative Group, Landray MJ, Haynes R, Hopewell JC, Parish S. Effects of Extended-Release Niacin with Laropiprant in High-Risk Patients. N Engl J Med. 2014; 371: 203-212. Ref.: https://goo.gl/p8fvjj
  11. Lim MY, Deal AM, Kim S, Musty MD, Conard J, et al. Thrombophilic Risk of Individuals with Rare Compound Factor V Leiden and Prothrombin G20210A Polymorphisms: An International Case-Series of 100 Individuals. Eur J Haematol. 2016; 97: 353-360. Ref.: https://goo.gl/zGBkQa
  12. Baglin T Gray E, Greaves M, Hunt BJ, Keeling D, Machin S, et al. Clinical guidelines for testing for heritable thrombophilia. Br J Haematol. 2010; 149: 209-220. Ref.: https://goo.gl/4DkCFV
  13. Bates SM, Greer IA, Middeldorp S, Veenstra DL, Prabulos AM, et al. VTE, thrombophilia, antithrombotic therapy, and pregnancy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed. American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012; 141: 691S-736S. Ref.: https://goo.gl/JgkxfD
  14. Brouwer JL, Lijfering WM, Ten Kate MK, Kluin-Nelemans HC, Veeger NJ, et al. High long-term absolute risk of recurrent venous thromboembolism in patients with hereditary deficiencies of protein S, protein C or antithrombin. Thromb Haemost. 2009; 101: 93-99. Ref.: https://goo.gl/2zTp7f
  15. Puricel S, Lehner C, Oberhänsli M, Rutz T, Togni M, et al. Acute coronary syndrome in patients younger than 30 years--aetiologies, baseline characteristics and long-term clinical outcome. Swiss Med Wkly. 2013; 143: 13816. Ref.: https://goo.gl/i7lBzs
  16. Heffernan KS, Karas RH, Patvardhan EA, Jafri H, Kuvin JT. Peripheral arterial tonometry for risk stratification in men with coronary artery disease. Clin Cardiol. 2010; 33: 94-98. Ref.: https://goo.gl/6meeF8
  17. Poredos P, Jezovnik MK. Testing endothelial function and its clinical relevance. J Atheroscler Thromb. 2013; 20: 1-8. Ref.: https://goo.gl/cjjnI6
  18. Cai A, Li L, Zhang Y, Mo Y, Mai W, et al. Lipoprotein(a): a promising marker for residual cardiovascular risk assessment. Dis Markers. 2013; 35: 551-559. Ref.: https://goo.gl/zejdSa
  19. Roeseler E, Julius U, Heigl F, Spitthoever R, Heutling D, et al. Lipoprotein Apheresis for Lipoprotein(a)-Associated Cardiovascular Disease: Prospective 5 Years of Follow-Up and Apo(a) Characterization. Arterioscler Thromb Vasc Biol. 2016; 36: 2019-2027. Ref.: https://goo.gl/gDVhwh
  20. Klingel R, Heibges A, Fassbender C, Pro(a)LiFe-Study Group. Prevention of cardiovascular complications in patients with Lp(a)-hyperlipoproteinemia and progressive cardiovascular disease by long-term lipoprotein apheresis according to German national guidelines. Clin Res Cardiol Suppl. 2017. Ref.: https://goo.gl/MNo4h3
  21. Leebmann J, Roeseler E, Julius U, Heigl F, Spitthoever R, et al. Lipoprotein apheresis in patients with maximally tolerated lipid-lowering therapy, Lipoprotein(a)-hyperlipoproteinemia, and progressive cardiovascular disease: prospective observational multicenter study. Circulation. 2013; 128: 2567-2576. Ref.: https://goo.gl/xC7jNI
  22. Frolow M, Drozdz A, Kowalewska A, Nizankowski R, Chlopicki S. Comprehensive assessment of vascular health in patients; towards endothelium-guided therapy. Pharmacol Rep. 2015; 67: 786-792. Ref.: https://goo.gl/q5ZUpl

Similar Articles

Recently Viewed

Read More

Most Viewed

Read More

Help ?