Robarts Research Institute, Canada.
Department of Physiology & Pharmacology, Canada.
Trends Cardiovasc Med. 2021 Jul;31(5):305-311. doi: 10.1016/j.tcm.2020.06.001. Epub 2020 Jun 7.
Elevated levels of lipoprotein(a) [Lp(a)] have been identified as an independent and causal risk factor for atherosclerotic cardiovascular disease (ASCVD) and, more recently, calcific aortic valve disease (CAVD). CAVD is a slow, progressive disorder presenting as severe trileaflet calcification known as aortic valve stenosis (AS) that impairs valve motion and restricts ventricular outflow. AS afflicts 2% of the aging population (≥ 65 years) and tends to be quite advanced by the time it presents clinical symptoms of exertional angina, syncope, or heart failure. Currently, the only effective clinical therapy for AS patients is surgical or transcatheter aortic valve replacement. Evidence is accumulating that Lp(a) can exacerbate pathophysiological processes in CAVD, specifically, endothelial dysfunction, formation of foam cells, and promotion of a pro-inflammatory state. In the valve milieu, the pro-inflammatory effects of Lp(a) are manifested in valve thickening and mineralization through pro-osteogenic signaling and changes in gene expression in valve interstitial cells that is primarily facilitated by the oxidized phospholipid content of Lp(a). In AS pathogenesis, an incomplete understanding of the role of Lp(a) at the molecular level and the absence of appropriate animal models are barriers for the development of specific and effective clinical interventions designed to mitigate the role of Lp(a) in AS. However, the advent of effective therapies that dramatically lower Lp(a) provides the possibility of the first medical treatment to halt AS progression.
脂蛋白(a) [Lp(a)]水平升高已被确定为动脉粥样硬化性心血管疾病 (ASCVD) 的独立和因果风险因素,最近也被确定为心脏瓣膜钙化疾病 (CAVD) 的风险因素。CAVD 是一种缓慢进行的疾病,表现为严重的三叶瓣钙化,称为主动脉瓣狭窄 (AS),会影响瓣膜运动并限制心室流出。AS 影响 2%的老年人群(≥65 岁),并且在出现劳力性心绞痛、晕厥或心力衰竭等临床症状时往往已经相当严重。目前,AS 患者唯一有效的临床治疗方法是手术或经导管主动脉瓣置换术。越来越多的证据表明,Lp(a) 可加重 CAVD 的病理生理过程,特别是内皮功能障碍、泡沫细胞形成和促炎状态。在瓣膜环境中,Lp(a) 的促炎作用表现为通过促成骨信号和瓣膜间质细胞基因表达的变化导致瓣膜增厚和矿化,主要由 Lp(a) 的氧化磷脂含量介导。在 AS 的发病机制中,对 Lp(a) 在分子水平上的作用缺乏完整的理解以及缺乏合适的动物模型,这是阻碍开发旨在减轻 Lp(a) 在 AS 中作用的特异性和有效临床干预措施的障碍。然而,能够显著降低 Lp(a) 的有效治疗方法的出现,为首次使用药物治疗来阻止 AS 进展提供了可能。
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