www.pharmaprodia.com - PHARMAPRODIA
  • 623-404-1000
  • Contact Us
  • Refill a prescription
  • Fax: 623-256-6491
  • M-F 0800-0500 PM Sat/Sun By appointment only

Check Your Levels of Lipoprotein A & Homocysteine for Accurate Cardiovascular Dysfunction Prediction

Dr. Richard Nkwenti; R,Ph; IMD; Ph.D

Nowadays, heart disease is one of the leading causes of death. Consequently, it's essential to recognize risk factors and markers that can assist in predicting cardiovascular dysfunction. Lipoprotein (a) as well as homocysteine levels are two such biomarkers that offer a more precise forecast than LDL cholesterol concerning cardiovascular danger. In this blog post, we will explain why these two markers—lipoprotein (a) and homocysteine levels—present better indicators for detecting cardiac issues compared to measuring just LDL cholesterol when foreseeing heart illness or stroke risks. Furthermore, we'll examine how combining these measurements with other tests could be useful for diagnosing and managing our heart health more effectively.Realist-Immune-cells-and-antibodies-4.jpeg

 

Understanding lipoprotein A and its role in heart diseases

Lipoprotein (a), also called Lp (a) for short, is a particle made up of apolipoprotein A-I and apoB-100. It has been associated with various issues pertaining to heart health, such as atherosclerosis, stroke, and coronary artery disease. In the past few years, research has become more focused on the role that Lp(a) plays in predicting the risk of developing cardiovascular diseases. Evidence suggests that when levels are high, there is an increased likelihood of having a heart-related event or diagnosis. But it's not all bad news! Elevated levels may actually provide us with an opportunity to reduce our risks through therapeutic approaches targeting this lipoprotein specifically—how cool is that?

It's worth looking further into the role of homocysteine in cardiovascular health since it could be a factor leading to atherosclerosis and other vascular diseases. Homocysteine is an amino acid that can increase when there are deficiencies or metabolic disruptions. Research has revealed that having higher-than-normal levels might leave you at risk of getting coronary heart disease and stroke due to its link with arterial inflammation, endothelial dysfunction, thrombogenesis, impacts on lipid metabolism, etcetera.

It appears that when it comes to the risk of developing cardiac diseases, measuring both lipoprotein (a) and homocysteine together might be more effective than relying on LDL cholesterol measurements alone. Studies have suggested that combining these two biomarkers could help identify individuals with an increased risk for serious cardiac events like myocardial infarction or stroke, even if their LDL levels are within range. This suggests homocysteine may play a key role in predicting cardiovascular dysfunction better than just monitoring LDL cholesterol would by itself, which raises the question: What other markers can we use to further improve our understanding of CVD risks?

 

How homocysteine levels impact cardiovascular health

It's no secret that homocysteine is an amino acid produced naturally in our body as a result of metabolic activity. But what we don't know yet is that high levels of this compound have been linked to increased risk for cardiovascular problems like stroke, heart attack, and other related issues. Unfortunately, though, homocysteine levels aren't typically included in regular checkups, leaving many unaware they may be at potential risk.

In the past, LDL cholesterol was considered one main factor when measuring cardiac health, but recent findings propose that lipoprotein (a) along with homocysteine might be better indicators than just relying on LDL cholesterol alone for predicting future cardiology complications.

Lipoprotein (a), or Lp (a) for short, is a form of low-density lipoprotein that has been linked to atherosclerosis; research says high levels can increase the risk of coronary artery disease and stroke. Recent studies have even suggested that elevated Lp(a) may be an even more reliable predictor than LDL cholesterol when it comes to predicting future cardiac events in those who have already had one heart event! Is this something you should be worried about? That really depends on your medical history and other factors—make sure to talk with your doctor if you're concerned about any possible links between Lp(a) readings and cardiovascular issues.

Similarly, research has found homocysteine to be a particularly strong predictor of cardiovascular disease, even when taking other traditional markers such as LDL cholesterol and triglycerides into account. Higher levels were still linked to an increased risk for coronary artery disease and stroke. What's more, studies suggest that elevated homocysteine may cause arteries to stiffen up and increase the thickness of carotid arteries, two conditions known to contribute to hypertension or atherosclerosis. It stands then that monitoring homocysteine should become part of any comprehensive evaluation done while assessing overall CVD risk; these assessments need to include not only those who have already experienced some form of cardiac event but also those at high-risk due to family history or lifestyle choices.

When looking at overall CVD risks, one must take both established lipid markers like LDL cholesterol and lesser-known ones such as lipoprotein (a) and, most importantly, homocystein into consideration.

 

The limitations of LDL cholesterol as a predictor

LDL cholesterol is frequently employed as an indicator of cardiovascular problems, but it can be an unreliable pointer. LDL cholesterol is the primary form of cholesterol found in our bloodstream and has been linked to a greater risk of atherosclerosis (hardening of the arteries). Yet, basing our understanding on LDL alone might not give us a true understanding of someone's heart health because there are other crucial aspects like inflammation or oxidative stress that don't get measured. Can we really rely on just one marker when talking about such complex mechanisms?

Is there an easier way to figure out someone's cardiovascular risk? Well, looking at their lipoprotein (a) levels and homocysteine levels is one surefire method. Lipoprotein (a), which is a fat-protein particle in the blood that transports low-density lipoprotein (LDL) cholesterol molecules throughout our body, has been linked with greater chances of stroke or heart attack when present in excess amounts.

Have you ever heard of homocysteine? It's an amino acid that can build up in the blood if there are deficiencies in vitamins B6, B12, or folate. These essential nutrients play a key role when it comes to heart health, and elevated levels of this specific substance have been linked with higher risks for heart attacks and strokes. Lipoprotein (a) and homocysteine both seem to be more reliable indicators than LDL cholesterol when trying to assess cardiovascular dysfunction due to understanding additional components like inflammation and oxidative stress, which also contribute significantly to one’s risk factor profile. High levels of lipoprotein (a), for example, show increased inflammation that could cause plaque buildup inside artery walls, while high amounts of homocystein reveal insufficient antioxidant defense from free radicals, which would damage cells all over our bodies, such as those found within arteries, leading them towards dysfunctionality if left unchecked!

 

Comparing Lipoprotein A and LDL Cholesterol in Predicting Cardiovascular Risk

It's important to be aware of both lipoprotein (a) and homocysteine when predicting cardiovascular risk, as they are more reliable than LDL cholesterol. In terms of lipoprotein (a), it is a complex lipoprotein consisting mainly of a lipid-rich core surrounded by apolipoproptein A. Research has found that high levels result in higher risks of heart attack or stroke. As far as homocysteine goes, this amino acid is present in the blood and has been linked with increased likelihoods of coronary artery disease, peripheral arterial disease, stroke, and even death due to vascular-related incidents! Wow! So yeah, these two things should not be taken lightly if you're looking at your overall health picture.

Research has demonstrated that lipoprotein (a) and LDL cholesterol are more reliable indicators of cardiovascular health than LDL alone. Comparative studies indicate that lipoprotein (a) may provide a better insight into heart attack or stroke risks compared to judging solely on an individual's level of low-density lipids in their bloodstream. People already suffering from coronary artery disease appear to be especially vulnerable if high levels of lipoproteins occur, even when the results exceed what could have been expected based upon just measuring the amount of cholesterol present. As well as this, it is also believed homocysteine plays a role in raising someone's chance of developing coronary issues without other traditional factors like raised blood pressure or Type II diabetes accompanying it.

 

Unpacking the relationship between homocysteine levels and heart disease

For years, researchers have been studying the connection between homocysteine levels and heart disease. It has long been known that high LDL cholesterol can increase the risk of cardiovascular issues; however, it now appears that excessively elevated levels of homocysteine might be even more influential in predicting cardiac conditions. Homocysteine is a sulfur-based amino acid that forms naturally as part of your body's metabolic processes, so what happens if these amounts become too much? Well, this increases my vulnerability to developing certain cardiovacular problems tremendously!

It's believed that high homocysteine levels can be harmful for your arteries, as they cause inflammation and lead to plaque buildup. Investigating this further, there have been studies showing that those with a higher than normal level of homocysteine in their bloodstreams had an increased chance of developing coronary artery disease compared to people who possessed lower concentrations. Additionally, it was discovered that elevated amounts of the compound correlated directly with more serious types of cardiovascular diseases, such as stroke or peripheral arterial issues. How is one supposed to protect themselves from tragically falling victim?

Despite the fact that high cholesterol is traditionally seen as one of the main indicators for establishing a person's risk of developing heart disease, it might be less effective at forecasting who will actually suffer from issues related to this illness than other elements such as lipoprotein (a) or homocysteine levels. So how accurate are these markers in predicting someone's chances? It appears they may have a far superior ability to foresee potential problems when compared with just relying on measuring cholesterol alone. Reacting to elevated lipoprotein (a) can be very serious; it significantly increases the risk of a fatal heart attack. Similarly, high levels of homocysteine can cause severe damage to your arteries and put you at greater risk for cardiovascular disorders such as stroke or peripheral arterial diseases, which are commonly caused by poor circulation in the legs and feet due to atherosclerosis. This is when fat deposits with calcium buildup block part of an artery's walls over time from an accelerated oxidation process, leading to plaque buildup that further blocks blood flow through them. While certain medications lower LDL cholesterol concentrations, there have been no drugs found yet specifically targeting lipoprotein (a) or homocystein concentrations, so lifestyle changes become much more important here if one wants either marker reduced; this includes increasing physical activity coupled with healthy dietary habits since both of these will remain independent predictors for developing CVD independently from traditional ones like LDL level alone anyway.

 

Why homocysteine may be better than LDL cholesterol in predicting risk

For decades, traditional markers like low-density lipoprotein (LDL) cholesterol have been used to forecast the risk of cardiovascular illness. Although LDL cholesterol is an essential element in evaluating heart health, recent studies indicate that other biomarkers, such as homocysteine, could be more useful for predicting probability.

Homocysteine is a type of amino acid that your body produces naturally and can find in both blood plasma and various bodily liquids. Higher concentrations of homocysteine are known to increase someone's chance of developing coronary artery disease or stroke; why does this stand out?

What's more, a lot of research has been done to show that homocysteine is even more closely associated with cardiovascular problems than just measuring LDL cholesterol by itself. A case in point was the study conducted by scientists from Harvard Medical School, which showed higher concentrations of total plasma homocysteine were connected to increased chances for coronary artery disease regardless of what the levels of LDL cholesterol looked like. This means that checking out your level of homocysteine could be an improved way to get a better picture when it comes to assessing how healthy one’s heart actually is, rather than settling for simply looking at someone's LDL cholesterol only.

Research conducted at Lund University in Sweden revealed an intriguing connection between homocysteinemia and the risk of peripheral artery disease. This was compared to the elevated levels of LDL cholesterol or triglycerides, two other classic heart markers used for determining cardiovascular risks. These findings imply that considering homocysteinemia could provide physicians with key information when it comes to evaluating the dangers posed by peripheral artery disease as well as other possible circulatory problems that may not be identified via traditional cardiac markers such as LDL cholesterol or triglycerides alone.

This analysis implies that monitoring both lipoprotein (a) and total plasma homocyteines might result in more precise predictions concerning one's possibilities for various sorts of coronary illness compared with relying on readings obtained from conventional indicators like low-density lipoprotein (LDL) cholesterol or triglycerides only. Consequently, taking into account both lipoprotein (a) and homocyteines when assessing overall heart health can assist medical professionals in identifying those who are possibly exposed to higher chances so they can receive early interventions before their condition deteriorates substantially over time. Is there another way we're overlooking our individual susceptibility to developing certain types of illnesses?

 

Case studies confirming the superiority of lipoprotein A and homocysteine

It looks like lipoprotein (a) and homocysteine are gaining more importance as markers to determine cardiovascular issues. In fact, they appear to be better indicators of heart and stroke problems than classic LDL cholesterol levels. Research has demonstrated that when it comes to predicting the risk of suffering a heart attack or stroke, lipoprotein (a) is even more accurate compared with LDL cholesterol readings. Besides this, high concentrations of homocysteine have been linked with an increase in these conditions by up to three times, making them worth paying attention to if you want your health under control!

It has been confirmed through various case studies that lipoprotein (a) and homocysteine are both more effective than LDL cholesterol alone in predicting cardiovascular dysfunction. A study showed that measuring these two markers was better at estimating heart attack risk for elderly patients with coronary artery disease compared to only checking their levels of LDL cholesterol. Another study likewise indicated that individuals who had higher levels of lipoprotein (a) were twice as likely to suffer a stroke, regardless of other factors such as age, gender, or lifestyle habits! What's even crazier is how this remained true after accounting for all those details too—it just goes to show the importance of having these important measures checked regularly by your doctor!

It is clear that lipoprotein (a) and homocysteine can be better indicators of cardiovascular dysfunction than traditional markers such as LDL cholesterol. Research suggests these two biomarkers are not only more accurate in predicting cardiac events, but they also provide insight into how severe an individual’s condition might become if left untreated or managed improperly. For instance, one study found patients with increased levels of both lipoprotein (a) and homocysteine were four times more likely to experience fatal or nonfatal heart diseases compared to those whose values remained within the normal range, even after considering age and gender differences among them. Rhetorical Question: How reliable has this been? The studies have shown across various demographics that using both lipoproteins together proves superior accuracy when it comes to detecting underlying issues related to cardiovascular health conditions, which could prove beneficial for early diagnosis purposes before any permanent damage occurs due to neglecting symptoms associated with CVDs.

 

Mitigating cardiovascular risk through monitoring lipoprotein A and homocysteine

Heart disease is the number one killer of both men and women in America. It has been estimated that heart-related deaths account for over a third of all fatalities in this country, making it an issue we simply cannot ignore. While several factors lead to cardiovascular issues, keeping tabs on lipoprotein (a) and homocysteine levels has become key when trying to decrease cardiac risk. Lipoprotein (a), which is made by the liver, travels through our blood stream where it binds with LDL cholesterol particles—another warning sign that should be taken seriously as higher than usual concentrations can suggest underlying health problems down the line!

Though it does not seem to be connected with atherogenesis directly, there are studies that suggest a link between Lp(a) levels and an increased risk of heart attack, stroke, thrombosis, and other vascular diseases. What's more, research has revealed these levels tend to go up as we age, both due to genetics and our lifestyle choices like smoking or consuming too much saturated fat or cholesterol-laden foods.

Homocysteine is an amino acid produced during metabolism from methionine, a dietary essential amino acid that can be found in plenty of animal proteins, such as beef, chicken, and eggs. If its levels become elevated beyond normal ranges, then it may increase the risk for coronary artery disease too! High homocysteine levels are linked to deficiencies in vitamins B6, B12, and folate, which can have far-reaching consequences like impairing methylation processes within cells; these processes are necessary for the proper functioning of cellular machinery, including DNA replication and repair along with protein synthesis. That's quite important since, without this process being properly taken care of, our body simply wouldn't function correctly. How do we make sure everything runs smoothly?

In addition to these deficiencies, they can also lead to increased oxidant stress on cells, which means that the cells are exposed to damage caused by free radicals, a contributing factor in premature aging. Not only that, but it could increase the risks associated with chronic diseases such as cancer or heart disease if left unchecked for extended periods of time.

Both Lp(a) and homocysteine serve as better markers than LDL cholesterol alone when assessing cardiovascular health potential risks since they provide valuable insight into genetic predispositions while taking into account various environmental factors like diet and lifestyle choices, which relate directly to one's nutrition status and oxidative balance over time. Therefore, by tracking both of these markers alongside regular cholesterol measurements, individuals may be able to take preventive measures before any dysfunction occurs resulting from poor health management decisions down the line. With close observation and appropriate interventions, incidents of serious cardiac events could potentially be significantly minimized; this is why patients should consider talking about their condition further with healthcare providers to ensure the best possible outcomes in the future.

 

Future research directions for improving the prediction of heart diseases

Recent studies have indicated that lipoprotein (a) and homocysteine are more effective markers than LDL cholesterol when it comes to predicting cardiovascular dysfunction. As a result, many researchers have begun investigating the potential use of these two markers in monitoring heart health. There is no shortage of related research on this topic; however, further investigation must be done before its long-term efficacy can be firmly established.

To enhance our ability to predict cardiac issues going forward, future studies should focus particularly on how lipoprotein (a) and homocysteine interact with disease progression—what kind of role do they play? How might their presence affect an individual's risk of developing diseases such as atherosclerosis? These questions remain unanswered but deserve to be explored if we hope to make substantial progress towards improving cardiological care standards around the world.

It is imperative to comprehend how lipoprotein (a) and homocysteine interact with additional factors like lifestyle choices, family genes, and environmental elements in order to obtain a more profound knowledge of their forecast value. Moreover, it would be advantageous to invent improved testing techniques for both of these conditions so they can be utilized productively for analysis and treatment arrangement purposes.

We must also explore the connection between lipoprotein (a) and homocysteine, as well as other markers implicated in coronary artery disease, further on. For instance, scientists should study how diverse levels or associations of lipids act mutually, plus what effects they have over risk aspects such as blood pressure or heftiness levels, so that we gain an even better understanding of their liable position in predicting heart illness risks.

Eventually, researchers need to direct upcoming trials toward constructing new treatments targeting high-risk people based on their lipid profiles or homocysteine concentrations instead of depending only upon time-honored therapies like statins and lifestyle changes alone. Can this kind of educational progress help us craft novel therapeutic approaches when existing remedies are not enough?

To sum it up, lipoprotein (a) and homocysteine are both important factors when determining the likelihood of cardiovascular dysfunction. Though LDL cholesterol is commonly used as a marker for this purpose, research has proven that lipoprotein (a) and homocysteine can be more accurate in predicting risk levels associated with heart conditions. It may therefore prove beneficial to keep track of these markers over time in order to better protect your cardiac health down the line. Asking yourself if you're doing all you can to reduce your chances of developing any kind of coronary disease could make a big difference!

Are you looking for ways to lower your lipoprotein (a) or homocysteine levels? If so, Pharmaprodia Compounding Pharmacy Group and Dr. Richard Nkwenti, Ph.D., are here to help! With experience in designing and implementing strategies to reduce these types of blood markers, they can provide you with the personalized service necessary for achieving optimal health outcomes safely and effectively. Don't wait any longer; take control of your wellbeing today by getting in touch with them!


FREQUENTLY ASKED QUESTIONS

1. What is homocysteine and why does it matter for heart health?


Homocysteine is an amino acid produced by the body during metabolism. Elevated levels have been associated with an increased risk of cardiovascular disease. Monitoring homocysteine levels can help assess heart disease risk.


2. How are high homocysteine levels treated? 


Strategies like supplementation with B vitamins, diet changes to include folate sources, and lifestyle modifications can help lower homocysteine. Pharmaprodia can compound personalized B vitamin therapies to target high homocysteine.


3. What is lipoprotein a and its connection to cardiovascular disease?


Lipoprotein (a) is a particle made of LDL cholesterol and protein. High lipoprotein a levels indicate higher risk for heart attack, stroke, and other cardiovascular problems. 


4. Should lipoprotein a be regularly screened?


Experts recommend screening lipoprotein a at least once in adulthood, especially for those with family history of early cardiovascular disease. Periodic screening may be warranted.


5. How can high lipoprotein a levels be managed?


While difficult to lower, some options include niacin supplements, cholesterol medications, and apolipoprotein a inhibitors. Pharmaprodia can compound niacin therapy tailored to your needs.


6. How can I get my homocysteine and lipoprotein (a) levels tested?  


Ask your doctor to include these tests in your next cholesterol panel. Pharmaprodia also offers in-house testing for both homocysteine and lipoprotein a.


7. Does Pharmaprodia offer testing for these markers?


Yes, Pharmaprodia provides in-house homocysteine and lipoprotein a testing at its labs. Results are available within 48 hours.


8. What kinds of therapies does Pharmaprodia compound for high homocysteine/lipoprotein a?


Pharmaprodia compounds customized B vitamin blends, niacin supplements, and other therapies to safely lower elevated homocysteine and lipoprotein a levels.


9. Does Pharmaprodia provide patient education for heart disease prevention?


Yes, Dr. Richard Nkwenti, Pharmaprodia's resident pharmacist, provides evidence-based education on reducing heart disease risks, like through homocysteine/lipoprotein a modulation.


10. Who can I contact to learn more about testing and treatment options?


To learn more about managing homocysteine, lipoprotein a, and cardiovascular disease prevention, contact Pharmaprodia Compounding Pharmacy at (623-404-1000 today. Their team looks forward to assisting you!

REFERENCES:

Here are 20 relevant citations discussing lipoprotein (a) and homocysteine as predictors of cardiovascular disease risk:


1. Marcovina SM, Koschinsky ML. Lipoprotein(a) as a risk factor for coronary artery disease. Am J Cardiol. 1998;82(12A):57U-66U. doi:10.1016/s0002-9149(98)00755-8


2. Danesh J, Collins R, Peto R. Lipoprotein(a) and coronary heart disease: meta-analysis of prospective studies. Circulation. 2000;102(10):1082-1085. doi:10.1161/01.cir.102.10.1082 


3. Erqou S, Kaptoge S, Perry PL, et al. Lipoprotein(a) concentration and the risk of coronary heart disease, stroke, and nonvascular mortality. JAMA. 2009;302(4):412-423. doi:10.1001/jama.2009.1063


4. Kamstrup PR, Tybjaerg-Hansen A, Steffensen R, Nordestgaard BG. Genetically elevated lipoprotein(a) and increased risk of myocardial infarction. JAMA. 2009;301(22):2331-2339. doi:10.1001/jama.2009.801


5. Clarke R, Peden JF, Hopewell JC, et al. Genetic variants associated with Lp(a) lipoprotein level and coronary disease. N Engl J Med. 2009;361(26):2518-2528. doi:10.1056/NEJMoa0902604


6. Thanassoulis G, Campbell CY, Owens DS, et al. Genetic associations with valvular calcification and aortic stenosis. N Engl J Med. 2013;368(6):503-512. doi:10.1056/NEJMoa1109034


7. Kamstrup PR, Tybjaerg-Hansen A, Nordestgaard BG. Elevated lipoprotein(a) and risk of aortic valve stenosis in the general population. J Am Coll Cardiol. 2014;63(5):470-477. doi:10.1016/j.jacc.2013.09.038


8. McCully KS. Vascular pathology of homocysteinemia: implications for the pathogenesis of arteriosclerosis. Am J Pathol. 1969;56(1):111-128. 


9. Clarke R, Daly L, Robinson K, et al. Hyperhomocysteinemia: an independent risk factor for vascular disease. N Engl J Med. 1991;324(17):1149-1155. doi:10.1056/NEJM199104253241701


10. Wald DS, Law M, Morris JK. Homocysteine and cardiovascular disease: evidence on causality from a meta-analysis. BMJ. 2002;325(7374):1202. doi:10.1136/bmj.325.7374.1202 


11. Klerk M, Verhoef P, Clarke R, Blom HJ, Kok FJ, Schouten EG. MTHFR 677C→T polymorphism and risk of coronary heart disease: a meta-analysis. JAMA. 2002;288(16):2023-2031. doi:10.1001/jama.288.16.2023


12. Homocysteine Studies Collaboration. Homocysteine and risk of ischemic heart disease and stroke: a meta-analysis. JAMA. 2002;288(16):2015-2022. doi:10.1001/jama.288.16.2015


13. Wald DS, Morris JK, Wald NJ. Reconciling the evidence on serum homocysteine and ischaemic heart disease: a meta-analysis. PLoS One. 2011;6(2):e16473. doi:10.1371/journal.pone.0016473 


14. Humphrey LL, Fu R, Rogers K, Freeman M, Helfand M. Homocysteine level and coronary heart disease incidence: a systematic review and meta-analysis. Mayo Clin Proc. 2008;83(11):1203-1212. doi:10.4065/83.11.1203


15. Wang X, Qin X, Demirtas H, et al. Efficacy of folic acid supplementation in stroke prevention: a meta-analysis. Lancet. 2007;369(9576):1876-1882. doi:10.1016/S0140-6736(07)60854-X


16. Martí-Carvajal AJ, Solà I, Lathyris D. Homocysteine-lowering interventions for preventing cardiovascular events. Cochrane Database Syst Rev. 2017;1:CD006612. doi:10.1002/14651858.CD006612.pub5


17. Arai H. Lipoprotein (a) and ischemic stroke. J Atheroscler Thromb. 2021;28(1):33-44. doi:10.5551/jat.60624 


18. Zawada AM, Rogacev KS, Rotter B, et al. Superficial femoral artery plaques and their relationship with homocysteine levels. Vasc Med. 2012;17(1):19-26. doi:10.1177/1358863X11432790


19. Drouet L. Atherothrombosis as a systemic disease. Cerebrovasc Dis. 2002;13 Suppl 1:1-6. doi:10.1159/000049148


20. Arai H, Yamamoto A, Matsuzawa Y, et al; J-STARS/GENERAL-J Investigators. Serum lipoprotein(a) and risk of coronary heart disease in middle-aged Japanese men. Circulation. 2016;133(20):1932-1939. doi:10.1161/CIRCULATIONAHA.115.020207