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Vol. 41. Núm. 5.
Páginas 437-439 (Maio 2022)
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Vol. 41. Núm. 5.
Páginas 437-439 (Maio 2022)
Letter to the Editor
Open Access
Lipoprotein(a) apheresis restores coronary microcirculation in refractory angina
A aférese da lipoproteinemia (a) restaura a microcirculação coronária na angina refratária
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Francesco Sbranaa,
Autor para correspondência
francesco.sbrana@ftgm.it

Corresponding author.
, Beatrice Dal Pinoa, Giovanni Donato Aquarob, Federico Bigazzia, Giuseppe Vergaroc, Tiziana Sampietroa
a Lipoapheresis Unit, Reference Center for Diagnosis and Treatment of Inherited Dyslipidemias, Fondazione Toscana “Gabriele Monasterio”, Pisa, Italy
b Magnetic Resonance Imaging Unit, Fondazione Toscana “Gabriele Monasterio”, Pisa, Italy
c U.O. Cardiologia e Medicina Cardiovascolare, Fondazione Toscana “Gabriele Monasterio”, Pisa, Italy
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Table 1. Patient's lipid profile.
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To the Editor:

The present report concerns a 54-year-old man with refractory angina who was referred for lipoprotein(a) [Lp(a)] apheresis (LA) because of Lp(a)-hyperlipoproteinemia. At 18-month follow-up, myocardial perfusion, assessed with stress cardiac magnetic resonance, was shown to improve, with progressive amelioration of anginal symptoms.

The patient began to suffer effort angina at the age of 53. In one year he had undergone multiple percutaneous coronary artery revascularizations, with chronic occlusion of the posterior descending artery (Figure 1). At his first admission to our lipid clinic, he was diagnosed with Lp(a)-hyperlipoproteinemia and polygenic hypercholesterolemia. He was receiving ranolazine 750 mg twice daily, aspirin 100 mg once daily, clopidogrel 75 mg once daily, and irbesartan 300 mg once daily. In the 6-min walk test angina appeared at 450 m; a baseline Seattle Angina Questionnaire (SAQ)1 was recorded. Carotid artery Doppler examination revealed intimal medial thickness <1 mm with 30% stenosis at the sinus bilaterally.

Figure 1.

Coronary angiography after multiple percutaneous coronary artery revascularizations (A, *) showing chronic occlusion of the posterior descending artery (B, arrowhead).

(0,14MB).

Considering the role of Lp(a)-hyperlipoproteinemia in the pathogenesis of refractory angina, LA was started2 and was repeated every two weeks, treating 5000 ml of plasma (about 2.0 times patient plasma volume) per session using dextran sulfate (Liposorber® LA systems; Kaneka) in addition to optimized lipid-lowering therapy (Table 1). Background pharmacological therapy was maintained unchanged. During 18 months of follow-up the patient presented progressive improvement in anginal symptoms: effort angina in the 6-min walk test regressed and an improvement in four of five domains of the SAQ was reported. The follow-up myocardial perfusion scan on stress cardiac magnetic resonance imaging showed improvement in the septal left ventricular wall perfusion defect and resolution of the lateral left ventricular wall perfusion defect (Figure 2).

Table 1.

Patient's lipid profile.

  TC (mg/dl) (120-200)  HDL (mg/dl) (>35)  TG (mg/dl) (<150)  LDL (mg/dl) (<160)  Non-HDL-C (mg/dl) (<130)  TC/HDL ratio (<4.5)  Lp(a) (mg/dl) (<50)  LLT 
Baseline  153  33  167  87  120  4.6  Atorvastatin 40 mg once daily 
Before LA  117  44  73  68  73  2.7  92  Rosuvastatin 10 mg once dailyFenofibrate 145 mg once dailyAcipimox 500 mg once daily 
After LA  61  41  43  11  NA  NA  15  Rosuvastatin 10 mg once dailyFenofibrate 145 mg once dailyAcipimox 500 mg once daily 

HDL: high-density lipoprotein; HDL-C: high-density lipoprotein cholesterol; LA: lipoprotein apheresis; LDL: low-density lipoprotein; LLT: lipid-lowering therapy; Lp(a): lipoprotein(a); NA: not applicable; TC: total cholesterol; TG: triglycerides.

Figure 2.

Stress and rest perfusion cardiac magnetic resonance (CMR) sequences showing improved perfusion in the left ventricular septal wall perfusion defect (red area) and resolution of the left ventricular lateral wall perfusion defect (yellow area). (A) Baseline rest perfusion CMR; (B) baseline stress perfusion CMR; (C) 18-month follow-up rest perfusion CMR; (D) 18-month follow-up stress perfusion CMR.

(0,16MB).

Refractory angina is a growing problem worldwide due to improved survival after revascularization procedures.3,4 The case reported supports the hypothesis that Lp(a)-hyperlipoproteinemia is a contributing factor in refractory angina: the apolipoprotein(a) [apo(a)] component of Lp(a) exhibits structural homology with plasminogen, enhances thrombosis and impairs fibrinolysis. Reduction of Lp(a) by LA improves thrombotic and fibrinolytic parameters in patients with refractory angina,5 enables restoration of endothelial function,6 and reduces the incidence of cardiovascular events in patients with Lp(a)-hyperlipoproteinemia.7 In addition, a unified view of Lp(a) in cardiovascular medicine draws attention to the advantages of associating cascade screening with personalized therapy.8

Until apo(a) antisense therapy becomes available, LA may represent an effective long-term treatment for refractory angina in those with Lp(a)-hyperlipoproteinemia that may improve myocardial perfusion, angina symptoms and quality of life.

Funding

No financial support was received.

Conflicts of interest

The authors have no conflicts of interest to declare.

Acknowledgments

The authors are grateful to Mascia Pianelli and Roberta Luciani for their excellent work in the apheresis unit.

References
[1]
J.A. Spertus, J.A. Winder, T.A. Dewhurst, et al.
Development and evaluation of the Seattle Angina Questionnaire: a new functional status measure for coronary artery disease.
J Am Coll Cardiol, 25 (1995), pp. 333-341
[2]
A. Padmanabhan, L. Connelly-Smith, N. Aqui, et al.
Guidelines on the use of therapeutic apheresis in clinical practice: evidence-based approach from the Apheresis Applications Committee of the American Society for Apheresis. The Eighth Special Issue.
J Clin Apheresis, 34 (2019), pp. 171-2354
[3]
T.Z. Khan, L. Hsu, A.E. Arai, et al.
Apheresis as novel treatment for refractory angina with raised lipoprotein(a): a randomized controlled cross-over trial.
Eur Heart J, 38 (2017), pp. 1561-1569
[4]
S. Madeira, C. Brízido, L. Raposo, et al.
Non-pharmacological treatment of refractory angina: the coronary sinus reducer, the new kid on the block.
Rev Port Cardiol, 40 (2021), pp. 371-382
[5]
T.Z. Khan, D.A. Gorog, D.J. Arachchillage, et al.
Impact of lipoprotein apheresis on thrombotic parameters in patients with refractory angina and raised lipoprotein(a): findings from a randomized controlled cross-over trial.
J Clin Lipidol, 13 (2019), pp. 788-796
[6]
T. Sampietro, M. Tuoni, M. Ferdeghini, et al.
Plasma cholesterol regulates soluble cell adhesion molecule expression in familial hypercholesterolemia.
Circulation, 96 (1997), pp. 1381-1385
[7]
F. Bigazzi, F. Sbrana, D. Berretti, et al.
Reduced incidence of cardiovascular events in hyper-Lp(a) patients on lipoprotein apheresis. The G.I.L.A. (Gruppo Interdisciplinare Aferesi Lipoproteica) pilot study.
Transfus Apher Sci, 57 (2018), pp. 661-664
[8]
B. Dal Pino, F. Sbrana, M. Coceani, et al.
Lipoprotein(a) in familial hypercholesterolemia: tips from family history.
Rev Port Cardiol, 40 (2021), pp. 225-227
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