I simply learn yet one more article praising the brand new messiah of cardiology (Lipoprotein(a)) and urging each doctor in America to begin testing for it. The tone was acquainted: solemn, scientific, and just a little evangelical.
The message? “Measure Lp(a) as soon as in each affected person.”
The subtext? “As a result of we lastly discovered the lacking piece.”
If this looks like déjà vu, that’s as a result of it’s. We’ve been right here earlier than: first with complete ldl cholesterol, then LDL, then HDL (our “good” ldl cholesterol that turned out to not be so good), and niacin, the vitamin-turned-savior-turned-villain. Each decade, cardiology anoints a brand new molecule to absolve the final one’s sins. Lp(a) is just the subsequent messiah within the lipid church, one other goal promising redemption with out ever questioning the creed.
Genetic fatalism will not be physiology.
Sure, Lp(a) is essentially genetic. However so are freckles, hair shade, and tone deafness. To declare one thing untreatable just because it’s heritable is to confuse inheritance with inevitability. Lp(a) will not be future; it’s a sign, and one which rises throughout irritation, an infection, and vascular damage.
That nuance was lacking totally from the reward piece I simply learn. The creator framed Lp(a) as a static villain, not a dynamic participant within the physique’s immune orchestra. It’s an acute-phase reactant, not an murderer.
“Take a look at everybody as soon as”: the brand new ritual
Requires common Lp(a) screening sound virtuous however functionally do nothing. What’s going to we do with the end result? Inform 20 p.c of our sufferers that their Lp(a) is excessive after which what?
There’s no FDA-approved remedy that lowers Lp(a) and improves survival. We’ll simply inform them they’re high-risk, intensify statins, and name it precision medication. In actuality, we’ve added one other quantity to frighten sufferers with out bettering outcomes.
That is ritualistic medication, not preventive care. Screening with out a confirmed intervention is like taking attendance on the apocalypse.
Therapeutic nihilism disguised as progress
The Lp(a) gospel ends, as all lipid sermons do, with a biotech benediction: “New medicine are on the best way.” We’ve heard that earlier than.
Keep in mind torcetrapib, dalcetrapib, and anacetrapib? They raised HDL spectacularly (as much as 130 p.c) and nonetheless failed to avoid wasting a single life. AIM-HIGH niacin trials collapsed in related vogue. Even PCSK9 inhibitors, which modestly decrease Lp(a), have but to point out convincing all-cause mortality profit.
We maintain mistaking biochemical success for medical salvation. That’s not science; it’s sacrament.
What the puff items by no means say
They by no means point out that Lp(a) might serve a restore perform, binding to broken endothelium the best way organic duct tape seals leaks. They by no means point out that continual an infection and irritation (not ldl cholesterol alone) drive the vascular hearth that recruits Lp(a) within the first place.
Drs. J. Thomas Grayston and Allan Shor confirmed Chlamydia pneumoniae hiding inside arterial plaques a long time in the past. However as a substitute of following that lead, medication buried it underneath LDL trials and advertising and marketing budgets.
Now we’re resurrecting one other quantity to distract from the identical unresolved query: Why is the artery infected within the first place?
The approaching pharmacologic resurrection
In fact, pharma sees alternative in religion. Antisense medicine like pelacarsen and olpasiran promise to “silence” Lp(a). Wall Avenue is thrilled. However till Lp(a)HORIZON or OCEAN(a)-Outcomes present precise occasion discount (not simply fairly graphs) that is advertising and marketing in a lab coat.
Abbott’s $3.7 billion niacin debacle ought to have cured us of blind devotion, however cardiology by no means met a biomarker it couldn’t worship.
The true heresy
Right here’s the uncomfortable fact: if 20 p.c of individuals have excessive Lp(a) but 80 p.c of coronary heart assaults happen in folks with regular ranges, possibly Lp(a) isn’t the murderer, simply one other bystander on the crime scene.
We maintain tracing chalk outlines round molecules whereas the true killer (continual infection-driven irritation) walks free.
Lp(a) often is the subsequent huge factor to measure, however measurement will not be medication. Till we perceive why the endothelium requires these lipoproteins (why restore turns to scar, why irritation by no means resolves) we’ll maintain baptizing biomarkers and questioning why the arteries maintain burning.
A last confession
As a recovering lipidologist, I’m not dismissing Lp(a). I’m simply declining to kneel earlier than it.
Coronary heart illness isn’t a lab worth; it’s a organic response to damage.
And till cardiology faces that, it is going to maintain looking for new messiahs whereas the true pathology (an infection, irritation, and immune dysregulation) continues its quiet campaign.
Larry Kaskel is an internist and “lipidologist in restoration” who has been working towards medication for greater than thirty-five years. He operates a concierge observe within the Chicago space and serves on the educating school on the Northwestern College Feinberg College of Drugs. As well as, he’s affiliated with Northwestern Lake Forest Hospital.
Earlier than podcasts entered mainstream tradition, Dr. Kaskel hosted Lipid Luminations on ReachMD, the place he produced a library of greater than 4 hundred packages that includes main voices in cardiology, lipidology, and preventive medication.
He’s the creator of Dr. Kaskel’s Residing in Wellness, Quantity One: Let Meals Be Thy Drugs, works that mix evidence-based medical observe with accessible methods for bettering healthspan. His present initiatives deal with reevaluating the ldl cholesterol speculation and investigating the infectious origins of atherosclerosis. Extra info is offered at larrykaskel.com.
