Darren Ali says the only warning sign that he was going to suffer a “widowmaker” while otherwise healthy at age 45 was some upper back pain.
Then, three months later, he had a massive heart attack.
“It’s almost like an elastic band’s tightening inside your chest,” said Ali, now 52, who lives in Maple Ridge, B.C.
Had Ali taken a simple blood test earlier in life, he might have known that he has high levels of a genetically-determined, cholesterol-carrying particle circulating in his bloodstream. He might also have known he was at increased risk of a heart attack because of that particle, and he might have been better able to prevent it.
Research indicates that about one in five Canadians — roughly eight million people — have high levels of Lipoprotein(a), or Lp(a), putting them at greater risk of a heart attack or stroke. And yet, many people have no idea because there is no routine screening for Lp(a), which also has no symptoms.
That’s something experts have been wanting to change.
Updated guidance created by a group of doctors for the Canadian Lp(a) Working Group, and published this month in the Canadian Journal of Cardiology, aims to increase awareness among family physicians who might not be as familiar with Lp(a).
Researchers warn Lipoprotein(a), a driving factor in unexpected heart attacks among younger and otherwise healthy people, is being missed by routine cholesterol tests. Researchers now recommend getting testing for elevated Lp(a) levels.
The guidance describes risks and treatments and builds on past recommendations, which have strongly suggested one-time screening for all Canadian adults to better identify those with elevated Lp(a). That’s in keeping with the recommendations released last month by the American College of Cardiology.
“When we consider all of the potential things to be measured, this is a very important one to prevent one of the most common causes of death amongst Canadians,” said Dr. Sonia Anand, a professor of medicine and epidemiology at McMaster University in Hamilton, Ont., and one of the authors of the updated guidance.
What is Lp(a)?
Lipoprotein(a) is part protein and part fat — everyone has it circulating in their blood.
Higher levels of Lp(a) can be dangerous because it’s stickier than other types of cholesterol, which allows it to more easily attach to the walls of blood vessels.
If it builds up too much, it creates plaques that can block the flow of blood to organs like the heart and the brain. Too much plaque and the blood vessels could burst, leading to a heart attack or stroke.
Lp(a) can also increase the risk of clots and promote inflammation, which increases the risk of plaques rupturing.
“If it’s elevated, an individual may have a two- to four-fold increased risk of a cardiovascular event, and there are things we can do to lower the individual’s risk,” said Anand.
According to the updated guidance, a person is considered to have an elevated risk if their levels are equal to or greater than 100 nanomoles per litre.
It says someone with levels equal to or greater than 190 nanomoles per litre is at an even higher risk.
How to manage Lp(a) levels
Since Lp(a) levels are mostly determined by your genes, there’s nothing you can do to change them, Anand said, and they’re unlikely to significantly shift over your lifetime.
There are some exceptions. Lp(a) levels are known to increase during pregnancy and in post-menopausal women, for example.
Because of the genetic component, if someone in your immediate family has high levels, that means you should also get checked, says Dr. Alykhan Abdulla, a family doctor in Manotick, Ont.
There are also a few other conditions that could be a signal for doctors to test further.
“We’re looking for people that have known heart disease, known stroke, known dementia, kidney problems, obesity, fatty liver and … erectile dysfunction,” said Abdulla, who did not contribute to the new guidance document.
People of African or Caribbean descent, as well as those who are of South Asian ancestry, are more likely to have elevated levels, according to research published in 2022.
What is the screening test?
Routine cholesterol testing does not include Lp(a) testing, which Dr. Jodi Heshka says requires a specific blood test — one the Canadian Cardiovascular Society notes is covered by all Canadian provinces.
Heshka, a cardiometabolic specialist at the Ottawa Heart Institute, says she’d support making the blood test part of routine screening.
“I would really encourage patients to ask about it, ask their health-care providers,” she said.
WATCH | Signs of a heart attack:
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Dr. Shazma Mithani discusses how to recognize when one happens, the steps you should take, and what you can expect at a hospital.
What can I do to treat this?
Lifestyle changes, like having a better diet or exercising more, won’t actually lower Lp(a), says Anand — though they’re still important things to do for your overall health.
There is also no type of medication currently that specifically lowers Lp(a), though there are several ongoing trials to identify drugs that can help.
For now, someone who is diagnosed with elevated levels, will usually be prescribed statin medications. These don’t lower Lp(a); they actually target another type of bad cholesterol, called low-density lipoprotein (LDL), which acts to compensate for the increased Lp(a).
‘Every Canadian really should be tested’
Despite the limited treatment options, doctors like Anand say “knowledge is power” and knowing ahead of time could help you prevent a heart attack or at least make you more aware of early warning signs.
Ali, who is currently part of a drug trial, says he’s hopeful new medication can help others — including his own children.
“My youngest daughter actually has a lipoprotein(a) level higher than I did when I had my heart attack,” said Ali.
“She’s actually already on statins and she’s only 25. … It just takes a simple blood test. This is something every Canadian really should be tested for.”
