Growing up in West Africa, I was aware of individuals dying at a young age. My mother, a trained pediatrician working as a family medicine physician, explained to me that the death of men and women in their 40s or 50s was commonly attributed to strokes or heart attacks. Today, I look back and wonder about the underlying causes of these heart attacks and strokes. Was there a familial component? Could early intervention in childhood have saved lives?

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Lipoprotein A is an independent risk factor for coronary artery disease (Langsted A, et al. J Am Coll Cardiol. 2019;74:54-66). It is composed of two main parts: apolipoprotein A and apolipoprotein B. Apolipoprotein A has a structure similar to plasminogen and may inhibit fibrinolysis, increasing the risk of clot formation or thrombosis. Apolipoprotein B promotes the deposition of plaques of fatty material in the arterial wall, increasing the risk of heart attack.

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Elevated levels of lipoprotein A is an inherited trait. Diet and exercise do not affect lipoprotein A levels (Rawther T, Tabet F. J Mol Cell Cardiol. 2019;131:1-11).

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Individuals may be unaware they have this trait. Thus, an athlete with elevated lipoprotein A could have a heart attack or stroke at an early age, which may result in physical impairments or death. Therefore, awareness, education, and monitoring of this condition in childhood is needed.

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Children in my pediatric practice are screened for a family history of early cardiovascular disease. We look for a history of heart attack, stroke, angina, and positive stress test in male family members 55 and under and in female family members 65 and under. We then test all children with a positive family history for elevated lipoprotein A levels (>50 mg/dL). Lipoprotein A levels do not vary much throughout a person’s lifespan. Patients with elevated levels of lipoprotein A are referred to the pediatric lipid clinic.

Certain medications such as exogenous estrogen found in birth control pills also can increase the risk of stroke in a person with elevated lipoprotein A levels (Stubblefield PG. Int J Fertil. 1989;34 Suppl:40-49). Therefore, people who take these drugs should be educated on the associated risks.

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Development of effective treatments to lower lipoprotein A levels requires a study of how the condition appears in all subsets of the population. More studies are needed to evaluate cholesterol, heart disease, and stroke in Black, South Asian, and Hispanic populations who have a higher prevalence of dyslipidemia (Vibhuti S, Deedwania P. Curr Atheroscler Rep. 2006;8:32-40).

In summary, lipoprotein A is an inherited risk factor for early heart attack or stroke. This inherited trait is not well understood. Having a stroke or heart attack has become so commonplace that these events no longer surprise us. Yet in some instances, the tragedy could be prevented by early identification and close follow-up.

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Pediatricians should consider screening every patient for a family history of early cardiovascular events. Of special consideration are patients seeking birth control as well as transgender individuals receiving estrogen treatment. If patients have a family history of early heart attack or stroke, or if family history is unknown, a measurement of lipoprotein A level should be considered. In this way, those with extremely high levels of lipoprotein A can be identified and monitored, lowering their risk for a cardiovascular event.

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Dr. Wright is on staff at South Sacramento Medical Center, Sacramento, Calif.