The challenge of secondary cardiovascular prevention in very high Lipoprotein (a) level: a case report.

Background: While advances in technology and procedural techniques have significantly improved outcomes post-PCI, two pharmacological strategies have gained particular attention for their effectiveness in reducing long-term cardiovascular (CV) risk: anti-platelet therapies and lipid-lowering therapies (LLT). The 10-year recurrence risk for major CV events remains as high as 10-30%, due to various pathophysiological pathways collectively known as residual risk (RR), even with optimal CV risk factor management after acute coronary syndrome (ACS). RR includes factors such as elevated lipoprotein(a) [Lp(a)], triglycerides, pro-thrombotic states, hyperglycemia, and persistent subclinical arterial inflammation. Aims: This case highlights the challenge of managing a patient with multiple recurrent cardiac ischaemic events and in-stent restenosis, despite good medical therapy and no other significant CV risk factors except for markedly elevated Lp(a) levels. Conclusion: Three critical aspects of daily practice emerge from our observation. First, Lp(a) is a valuable parameter for CV risk stratification in primary prevention. Second, measurement of Lp(a) post-CV event may provide valuable information on the risk of ischaemic recurrence, influencing decisions regarding long-term dual anti-platelet therapy (DAPT). Finally, this case illustrates the importance of a multidisciplinary approach in managing patients with very high cardiovascular risk. Close collaboration between cardiologists and lipidologists facilitated the identification of a rare lipid disorder and the decision to pursue lipoprotein apheresis, an intensive but effective treatment option for lipid metabolism disorders lacking conventional medical therapy.