High Lipoprotein (a) – Dead Man Walking?
Warning: Lipoprotein (a) and all this info is disconcerting stuff.
You know how you're always reading about some young-ish person dropping dead from a heart attack? All too often, they're athletes of some sort, people who were presumably in excellent shape.
And I'm not even talking about the scores of pro bodybuilders who are dropping dead with alarming frequency, although some of them certainly might have fallen victim to the subject of this article.
Sure, some people might have had some undisclosed congenital heart problem, but there's a fair chance it could have been elevated levels of a little-known blood factor called lipoprotein (a) that affects approximately one out of four or five people, depending on who's crunching the epidemiological numbers.
Lipoprotein (a) is also known as "sticky cholesterol" because it promotes blood clotting. Scientists suspect it's an evolutionary throwback, something that might have once been valuable to our primitive selves but not so much now.
Having high levels of lipoprotein (a) increases your chances of coronary heart disease, thickening of the aortic valves, stroke, or even heart failure by two to four times. It does this by being an inflammatory nightmare and depositing plaque like a splatter artist applies paint to a canvas.
Surprisingly, it doesn't correlate at all with conventional cholesterol levels. Many people who present with high levels of lipoprotein (a) have normal or even optimal cholesterol and triglyceride levels. Lipoprotein (a), thusly, might go a long way in explaining why only about 50% of the people who have heart attacks have undesirable cholesterol levels.
Unfortunately, conventional medicine says there's nothing you can do to lower lipoprotein (a), except for a ridiculously expensive, 6,000 dollar a year drug (Repatha) that insurance doesn't cover, or actually having your traumatized self hooked up to a machine while it slowly sucks out your blood and filters it of the offending substance.
As such, doctors who know about it MIGHT test your blood levels once but only once, never bothering to check it again because there's nothing they can do to remedy it, outside of the already mentioned heroic efforts.
Oh, they might advise you to take a statin, but the unfortunate truth is that statins often cause levels of lipoprotein (a) go UP. Point that inconvenient truth out to a doctor, though, and time how long it takes them to start coughing and then pretend they've got an urgent phone call awaiting them in the next room.
So, bottom line, many of us have this biological sword of Damocles hanging over our heads that might break free at any moment and deliver us into the arms of death. Some of us may be dead men walking, and medicine says there's nothing we can do about it.
Right now you're probably asking, as Scrooge did of his ghost advocate, "Speak comfort to me, TC," but, like Marley, I have none to give.
Well, maybe I do, but conventional medicine certainly doesn't believe in it. Before I get to them, though, let me tell you why I'm so interested in this little-known and little-discussed blood value.
I've known of lipoprotein (a) for several years but didn't pay much attention to it. Then along came a new personal physician who, unbeknownst to me, added the test for lipoprotein (a) to my standard blood panel.
It came back at 157 milligrams per deciliter, which is scary high. The normal or desirable level is less than 30, where anything over 50 is considered worrisome. Of course, some poor bastards have levels as high as 400 or more.
I was gobsmacked. Mind you, I'm a guy who practices what he preaches. All that stuff I write about? All those health and diet practices from the weird to the wonderful? I do them, or at least experiment with all of them. But this?
For once, I felt helpless.
The doctor told me I should just have a CT scan to determine my Coronary Artery Calcium (CAC) to see how much damage the lipoprotein (a) might have done. The test tells you just how much your arteries resemble the interior of a White Castle. If the score is low, you don't have much to worry about.
If it's high, you'd best start exercising and eating fewer White Castle burgers so you could improve all your other risk factors and presumably live long enough to see the cherry blossoms bloom again on the shores of the Potomac, or whatever else you might want to extend your life for.
The doctor would also recommend a statin, but like I said, statins have often been shown to raise lipoprotein (a) levels. That's like administering Mountain Dew to a diabetic; like treating a headache with a ball-peen hammer to the skull; like giving poison ivy to the outstretched hand from beneath the next stall when they needed toilet paper.
Anyhow, the CAC might show that lipoprotein (a) caused my arteries to look like the mine shaft that trapped those 33 Chilean miners – not completely blocked, but with only a small bore-hole through which blood could pass.
I already exercise and eat right, so what's the goddam point of having the test done? All it might do is paralyze me. I'd probably be afraid to work out, lest that last rep of squats Vasalva-ed loose a piece of plaque that then inconveniently lodged in some smaller blood vessel and caused me to stroke out.
Nope, no CAC assessment for me. I'll continue leading my presumably heart-healthy lifestyle and look for ways to lower my lipoprotein (a).
It's not entirely hopeless. There are at least a few logical strategies I can employ, some of which everyone should at least consider undertaking, even if they don't know whether they're one of the every four people that have scary lipoprotein (a) levels.
Doctors used to routinely prescribe taking 1 to 2 grams of niacin a day (about a hundred times the amount in a Centrum vitamin) to help combat high cholesterol in general, often in conjunction with statins. Then came the niacin death knell. A big Oxford University clinical trial funded by Merck involving 25,673 patients came up snake eyes.
Another niacin study, this one called the AIM-HIGH study, found equally disappointing results. Never mind that neither study took lipoprotein (a) into consideration. Doctors, en masse, dismissed the nutrient entirely, except for prescribing it to cure the one in a zillion cases of pellagra (which results from niacin deficiency) that might have popped up.
The dismissive doctors might have acted too soon, though. They probably didn't have time to read the study. If they had, they might have seen that the big Oxford study didn't just test pure niacin – they used a new concoction that combined niacin with another drug.
The thing about niacin is that it often causes a temporary but unpleasant flushing and/or rash. It's caused by an increase in the production of prostaglandins. Regardless, a lot of people find it annoying, so compliance is often low. Merck, however, devised a niacin formulation that contained another drug, one designed to alleviate the flushing and rash.
That means that the other drug might have somehow interfered with niacin's mojo. And the other study? The participants didn't even have abnormal lipid levels in the first place, so trying to elevate their HDL through niacin might have been futile.
Regardless, niacin is experiencing a bit of a resurgence. Smaller studies, along with the empirical evidence presented by a number of functional medicine doctors, indicate that plain ol' niacin can lower LDL cholesterol, raise HDL cholesterol, and lower triglycerides.
But more importantly, at least for the topic at hand, is that niacin appears to be one of the few things that can lower levels of lipoprotein (a) by a lot – as much as 20 to 80 percent.
Granted, you need to take a lot of it, from 2 to 6 grams a day, but it appears to work.
Large doses of niacin can increase blood sugar, possibly cause gout, and elevate some blood enzymes, but those can easily be monitored, and they're merely annoyances when you compare it what untreated high levels of lipoprotein (a) can lead to.
Oh, one other thing. Doctors claim large doses of niacin can cause liver damage. It's true, but again it's a result of people trying to avoid the niacin flush. Supplement manufacturers came up with sustained-release (SR) niacin, which leads to sustained levels of niacin with no flush. Great, but it's SR niacin that's been implicated in causing liver problems.
There's another type of niacin that mimics SR niacin without the liver problems. It's called extended-release (ER) niacin and it uses a different delivery system than SR niacin. Of course, people could just take the regular stuff and gut out the flush, which usually disappears in less than an hour. If, however, the flush is too much for someone to handle, they can also take their niacin with a bit of apple sauce, as the quercetin contained therein quells the flushing.
There are other supplements that appear to lower lipoprotein(a), but none of them appear to work as well as plain niacin.
According to Dr. Joel Kahn, an expert on dietary approaches to lowering lipoprotein(a), the amino acid L-carnitine might also drop levels by as much as 20 to 25%. Likewise, taking coenzyme Q10, the famous heart supplement, might bring it down 10%, as might regular intake of flaxseed.
Logically, you might assume that taking all this stuff together might K.O. your lipoprotein(a) levels into oblivion, but we don't know for sure since no one's going to shell out the kind of money needed for a study like that.
Other modest anti-lipoprotein (a) strategies include drinking coffee, using baby aspirin, and taking vitamin C (2 to 5 grams a day) and lysine (1500 mg.) together, these last two to fortify the blood vessels so they're able to withstand the damage caused by lipoprotein (a).
A blood test is the only way to tell if you're the one out of every four or five people that has elevated levels of lipoprotein(a).
That being said, if your doctor can't detect any heart murmur, you don't experience any shortness of breath, there's no chest tightness or pressure, your blood pressure and blood sugar are okay, and you have a desirable weight and waist circumference, you might just be okay. At least for the time being.
Oh, and one more thing. Sorry to get personal, but how are your erections? Solid? Unflagging? I ask because erections are often the canaries in the coal mine. High levels of lipoprotein(a) can cause plaque to form not only in your carotid artery, your kidney arteries, and your leg arteries, but your sexual organs too.
If your erections are less than what they were and it's not a result of old age, low testosterone, psychological demons, or an unenthused or unimaginative partner, it could be lipoprotein (a)'s handiwork.
The potential good news is that there's a new drug for the treatment of lipoprotein (a) on the horizon. It's currently in phase 3 testing, and preliminary results show that one shot a week decreases lipoprotein (a) levels by up to 80%. Of course, the FDA doesn't care about stats like that. They want proof it decreases the incidence of heart attacks, so keep your fingers crossed.
In the meantime, if you have elevated levels of lipoprotein (a), Dr. Kahn recommends you think about taking niacin. Start with 500 mg. twice a day and slowly increase the dose (adding another 500 mg. or so a week) until you reach 3,000 mg. a day. Kahn suggests an over-the-counter, extended-release brand named Endur-Acin, which is an extended-release formula.
(Remember to avoid the sustained-release niacin because it's been implicated in hepatotoxicity.)
You might also consider taking 2 grams per day of L-carnitine, as well as supplementing with 2 to 5 grams of vitamin C and 1500 mg. of lysine every day.
The preceding is exactly what I do. I won't know if it's working or not until my next blood test, but it at least gives me some peace of mind because I'm not just sitting around, waiting for the plumbing to gunk up; you know, rage rage against the dying of the light and all that.
Lastly, as I mentioned, exercise doesn't appear to lower lipoprotein (a) levels at all, but it'll improve all other risk factors. So yeah, keep doing that.
Even if you don't have elevated levels of lipoprotein(a), or if you just don't know and you don't want to know, you still might want to consider adding niacin to your supplement regimen for the following reasons:
- Niacin lowers LDL cholesterol in general.
- It also increases HDL cholesterol.
- Niacin has a greater effect on something called "atherogenic dyslipidemia" – a component of metabolic syndrome – than statins.
- It doesn't have the side effects of statins, like possible muscle pain and damage.
- Niacin increases nitric oxide production, which makes your veins pop out like major rivers on a topographic relief map.
- This same increased production of nitric oxide leads to better erections.
Of course, it probably wouldn't be prudent to take large doses unless high lipoprotein (a) was confirmed by a blood test. One or two 250 mg. pills a day, taken with a little applesauce to negate the flushing, might keep you from being a dead man walking.
- O'Connor A. A Heart Risk Factor Even Doctors Know Little About. The New York Times. January 9th, 2018.
- Herper M. Some Experts Defend Niacin for Heart Disease After Failed Study. Forbes. Mar 11, 2013.
- Serben MC et al. Impact of L-carnitine on plasma lipoprotein(a) concentrations: A systematic review and meta-analysis of randomized controlled trials. Sci Rep. 2016 Jan 12;6:19188. PubMed.
- Superko HR et al. Niacin and heart disease prevention: Engraving its tombstone is a mistake. J Clin Lipidol. Nov-Dec 2017;11(6):1309-1317. PubMed.
- Weitz B Lipoprotein (a) with Dr. Joel Kahn. Rational Wellness Podcast 166, July 22, 2020.
- LiverTox: Clinical and Research Information on Drug-Induced Liver Injury [Internet]. Bethesda (MD): National Institute of Diabetes and Digestive and Kidney Diseases; 2012-. PMID: 31643176.
- Luoma TC. Luoma's Big Damn Book of Knowledge. American Girl Publishing. Ishpeming, 3rd edition, 2019.
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