Perceptions on lipoprotein(a) testing and treatment in patients from the INTERASPIRE study: a commentary
Year: 2025
Type: article
Abstract: This invited commentary refers to ‘Patient perceptions on lipoprotein(a) testing and treatment for secondary prevention of cardiovascular disease: results from the INTERASPIRE study in seven countries across five World Health Organization regions’ by C.S. Jennings et al., https://doi.org/10.1093/eurjcn/zvaf174. Despite effective primary and secondary prevention strategies, cardiac complications continue to be experienced by those with ‘residual cardiovascular risk.’1 Lipoprotein(a) (Lp [a]) has recently acquired attention as a potential culprit behind this residual risk.2 This lipoprotein is genetically inherited and estimated to be six times more atherogenic per particle than low-density lipoprotein cholesterol.3 Unsurprisingly, a causal link between Lp(a) and cardiovascular disease (CVD) has been established, with elevated levels in patients reflecting a greater risk of recurrent myocardial infarction.4 However, from a worldwide perspective, clinical awareness of Lp(a) is limited, and widespread, large-scale testing is yet to be deployed. These issues are likely, in part, attributed to the absence of licensed, Lp(a)-lowering therapies. This innovative research by Jennings et al.,5 elucidates important gaps in our knowledge by evaluating patient knowledge and perceptions of CVD risk and their views on Lp(a) testing, consequences, and treatment. The study was part of a larger international cohort study (INTERASPIRE) of secondary preventive care in patients with coronary artery disease.6 Two groups of patients were identified across seven countries (China, Colombia, Kenya, Malaysia, Nigeria, Poland, and the United Arab Emirates): Those with elevated Lp(a) (≥50 mg/dL [≥115 mmol/L]) A random sample of those with normal Lp(a). In the elevated group, patients received an educational leaflet about Lp(a), which was based on the information booklet entitled ‘Living with elevated lipoprotein(a)’ created by ‘FH Europe’ [https://fheurope.org/lp-a/]. They were also advised to discuss this condition with their physician (cardiologist or family doctor) and subsequently participated in a telephone interview involving study-specific questionnaires. The random sample of patients with normal Lp(a) also completed questionnaires via a telephone interview. Both groups completed questionnaires developed by the study expert advisory group. Knowledge and perceptions of CVD risk were measured using an adapted version of the Attitudes and Beliefs about CVD Risk Questionnaire,7 with additional items included in the elevated Lp(a) version, to assess perceptions of risk related to this lipid biomarker. The questionnaire for patients with elevated Lp(a) also included items examining their opinions on Lp(a) testing for relatives, even in the absence of an available treatment. Moreover, it evaluated beliefs about the acceptability of Lp(a) testing, with this section developed using an adapted version of the Theoretical Framework of Acceptability questionnaire.8 A total of 856 patients completed the questionnaires. From this population, 333 (29.1% female) had elevated Lp(a) levels and 523 (22.6% female) had normal Lp(a) levels. Both groups demonstrated a similar knowledge of CVD, with a score of 62% in the normal Lp(a) group and 60% in those with elevated Lp(a) (P = 0.076). Knowledge of Lp(a) and its management in both groups was poor. Patients with elevated Lp(a) expressed concern about this condition, but found testing acceptable and appreciated the benefits. They were motivated to reduce their CVD risk despite the absence of medical therapies and were eager to receive advice. What has this study added to our knowledge of patient perceptions on Lp(a) testing and treatment for secondary prevention of CVD? Classic epidemiological methods were employed across each World Health Organization region, which generated a novel, multi-ethnic perspective from a large sample of patients. A number of salient, clinically relevant observations were made. First, knowledge and understanding of Lp(a) were limited in those with elevated levels. However, these patients were concerned about their results, which motivated them to receive guidance on leading a healthier lifestyle and achieving their risk factor targets, but more than a third of them reported significant challenges in receiving this advice from physicians. These issues suggest that the educational leaflet on Lp(a) was insufficient, and indeed may potentially reflect a lack of understanding regarding Lp(a) management in the physician community. This knowledge deficit is also documented in the wider literature.9 What are the implications for healthcare professionals? Like other people with CVD risks, those with elevated Lp(a) require professional, multi-disciplinary support. Healthcare professionals should be trained to dispel the misconception of a genetic risk being immutable. They should have the knowledge and skills to educate and empower people with elevated Lp(a) to make healthy lifestyle changes and adhere to prescribed medications, reducing overall CVD risk despite Lp(a) not currently being targeted therapeutically. Whilst some work is ongoing,10 there is an important requirement to develop and deploy innovative, pragmatic approaches to the education and training of healthcare professionals in the awareness and management of Lp(a), which is consistent with the recommendations of the European Atherosclerosis Society.11 Whilst this international study by Jennings et al.,5 was robust, there are two limitations that future work should seek to overcome. First, whilst the questionnaires were developed by an expert advisory group and based on theoretical frameworks and previous questionnaires, they were not validated. Fortunately, the authors report an aim to develop and publicly disseminate validated versions of these questionnaires, which will support a standardized approach to widely investigating this topic. Finally, consistent with many other clinical trials, the issue of gender bias arises as the study population was predominantly male. Given that women typically experience higher concentrations of Lp(a) than men, with an increase at menopause,12 future work should ensure equal representation of sexes. Altogether, elevated Lp(a) is an independent CVD risk factor, with prevalence rates of 20% and 30% in communities and patients with atherosclerotic CVD, respectively.11 Expert bodies recommend Lp(a) testing in all adults,11 however, this lipid remains overlooked in clinical practice.13 The paper by Jennings et al.,5 underscores a requirement for CVD-related healthcare professionals to improve their understanding of Lp(a) testing and management. Given their position and influence, this is a responsibility in which nurses and allied health professionals can excel, and a focus should be placed on equipping them to issue advice to patients on overall cardiovascular risk reduction in the absence of licenced therapies to treat Lp(a). In addition, this study also elucidates an opportunity for nurses involved in clinical trials to generate their own questions and augment the research by providing innovative clinical knowledge that has the potential to identify gaps and drive improvements in patient care. I am hopeful that the work of Jennings et al.,5 will be an inspiration to other clinical trial research nurses and encourage greater multi-disciplinary research endeavours. Donna Fitzsimons (PhD (Conceptualization [lead]; Validation [lead]; Visualization [lead]; Writing—original draft [lead]; Writing—review & editing [lead])), Gareth Thompson (PhD (Conceptualization [equal]; Validation [equal]; Visualization [equal]; Writing—original draft [equal]; Writing—review & editing [equal])), and Gemma Caughers (PhD (Conceptualization [equal]; Validation [equal]; Visualization [equal]; Writing—original draft [equal]; Writing—review & editing [equal])) No funding was received. There are no new data associated with this article.
Institution: Queen's University Belfast
Language: English
Subfield: Surgery
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W4416469545