D'Amuri Andrea, Di Gangi Pietro, Pagani Mauro, Lettieri Corrado
Medical Department, General Medicine Unit, Azienda Ospedaliera Carlo Poma, ASST Mantova, Str. Lago Paiolo 10, Mantova 46100, Italy.
Cardio-Thoracic-Vascular Department, Cardiology Unit, Azienda Ospedaliera Carlo Poma, ASST Mantova, Str. Lago Paiolo 10, Mantova 46100, Italy.
Eur Heart J Case Rep. 2025 Aug 9;9(9):ytaf389. doi: 10.1093/ehjcr/ytaf389. eCollection 2025 Sep.
While advances in technology and procedural techniques have significantly improved outcomes post-PCI, two pharmacological strategies have gained particular attention for their effectiveness in reducing long-term cardiovascular (CV) risk: anti-platelet therapies and lipid-lowering therapies (LLT). The 10-year recurrence risk for major CV events remains as high as 10-30%, due to various pathophysiological pathways collectively known as residual risk (RR), even with optimal CV risk factor management after acute coronary syndrome (ACS). RR includes factors such as elevated lipoprotein(a) [Lp(a)], triglycerides, pro-thrombotic states, hyperglycemia, and persistent subclinical arterial inflammation.
This case highlights the challenge of managing a patient with multiple recurrent cardiac ischaemic events and in-stent restenosis, despite good medical therapy and no other significant CV risk factors except for markedly elevated Lp(a) levels.
Three critical aspects of daily practice emerge from our observation. First, Lp(a) is a valuable parameter for CV risk stratification in primary prevention. Second, measurement of Lp(a) post-CV event may provide valuable information on the risk of ischaemic recurrence, influencing decisions regarding long-term dual anti-platelet therapy (DAPT). Finally, this case illustrates the importance of a multidisciplinary approach in managing patients with very high cardiovascular risk. Close collaboration between cardiologists and lipidologists facilitated the identification of a rare lipid disorder and the decision to pursue lipoprotein apheresis, an intensive but effective treatment option for lipid metabolism disorders lacking conventional medical therapy.
虽然技术和手术技术的进步显著改善了PCI术后的预后，但两种药物治疗策略因其在降低长期心血管（CV）风险方面的有效性而受到特别关注：抗血小板治疗和降脂治疗（LLT）。即使在急性冠状动脉综合征（ACS）后对CV危险因素进行了最佳管理，由于统称为残余风险（RR）的各种病理生理途径，主要CV事件的10年复发风险仍高达10%-30%。RR包括脂蛋白（a）[Lp（a）]升高、甘油三酯、血栓前状态、高血糖和持续性亚临床动脉炎症等因素。
本病例突出了管理一名患有多次复发性心脏缺血事件和支架内再狭窄患者所面临的挑战，尽管进行了良好的药物治疗，且除Lp（a）水平明显升高外无其他显著CV危险因素。
从我们的观察中可以看出日常实践的三个关键方面。首先，Lp（a）是一级预防中CV风险分层的重要参数。其次,CV事件后Lp（a）的测量可能为缺血复发风险提供有价值的信息，影响关于长期双联抗血小板治疗（DAPT）的决策。最后，本病例说明了多学科方法在管理心血管风险极高患者中的重要性。心脏病专家和脂质学家之间的密切合作有助于识别一种罕见的脂质紊乱，并决定采用脂蛋白分离术，这是一种针对缺乏传统药物治疗的脂质代谢紊乱的强化但有效的治疗选择。
