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High lipoprotein(a) levels are associated with increased risk of myocardial infarction in diabetics
Last reviewed: 02.07.2025
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People with diabetes were more likely to have a history of myocardial infarction (MI) if they also had high levels of serum lipoprotein(a), or Lp(a), or advanced liver fibrosis, a retrospective study using data from the Third National Health and Nutrition Examination Survey (NHANES III) found.
Compared with patients with diabetes and low Lp(a) levels (<10 mg/dL), multivariate analysis showed that the risk of nonfatal MI more than doubled at Lp(a) levels of 50 mg/dL or greater (P<0.001 for all):
- 50–99 mg/dL: adjusted odds ratio (aOR) 2.17 (95% CI 2.15–2.19)
- 100-149 mg/dL: aOR 4.20 (95% CI 4.14-4.27)
- ≥150 mg/dL: aOR 6.36 (95% CI 6.17-6.54)
Also, advanced liver fibrosis associated with nonalcoholic fatty liver disease (NAFLD) was associated with a 70% higher risk of nonfatal MI (aOR 1.70, 95% CI 1.68-1.72), Avika Atri, MD, of Jefferson Einstein Hospital in Philadelphia, reported at the annual meeting of the American Association of Clinical Endocrinology.
Patients who reported a history of MI had higher Lp(a) levels than those who did not report MI (mean 30.7 vs 24.2 mg/dL, respectively) and were more likely to have advanced liver fibrosis (13.5% vs 4.5%).
However, overall, individuals with advanced liver fibrosis had lower mean Lp(a) levels than those without advanced fibrosis (13.6 vs 25.9 mg/dL), even among those with prior MI (8.6 vs 34.2 mg/dL).
Lp(a) is produced by the liver, Atri explained, and circulating levels of Lp(a) in the body are determined by genetics. It is an established independent risk factor for atherosclerotic cardiovascular disease (ASCVD), and while increasing evidence links NAFLD to heart disease, the relationship between Lp(a), NAFLD, and MI risk has not been well studied in patients with diabetes.
Atry suggested that further studies are needed to determine optimal Lp(a) cutoff values for patients with diabetes and NAFLD to improve risk stratification and reduce ASCVD.
"If I had a patient who met these criteria — diabetes, nonalcoholic fatty liver disease, and heart disease — I would consider adding Lp(a) to the diagnostic panel," said session moderator Anunam Kotwal, MD, of the University of Nebraska at Omaha.
He said more information could help determine how aggressively to treat a patient to prevent a heart attack or mitigate further heart problems.
The cross-sectional analysis presented by Atri included a weighted sample of 3,330,795 individuals with diabetes aged 35 years and older from the NHANES III (1988–1994) database who had Lp(a) data collected.
Overall, the mean age of participants was 62 years, approximately 59% were women, and the median HbA1c was 7.7%. The prevalence of nonfatal MI was 13.3%, and 18% met criteria for NAFLD-related progressive liver fibrosis (defined as a Fibrosis-4 score of 2.67).
A higher proportion of patients in the MI group had Lp(a) levels above 50 mg/dL (about 30% versus 19% in those without MI).
Atri noted that limitations of the study include its cross-sectional nature and that, because it is interview-based, there is the potential for recall bias. Additionally, fatal MIs could not be assessed for association with Lp(a) or progressive liver fibrosis due to the study design.