Elevated Lipoprotein(a)-Associated Coronary Artery Disease in a 45-Year-Old Male

Premature coronary artery disease (CAD) in younger adults often arises from underrecognized risk factors such as elevated lipoprotein(a) (Lp(a)), a genetically determined lipoprotein with atherogenic and prothrombotic properties. We report a 45-year-old male with untreated hypertension, prior ischemic stroke, and significant tobacco use, who presented with exertional angina. Laboratory evaluation showed mildly elevated low-density lipoprotein cholesterol (LDL-C; 142 mg/dL), borderline low high-density lipoprotein cholesterol (HDL-C; 38 mg/dL), and markedly elevated Lp(a) (180 mg/dL). Coronary angiography revealed a chronic total occlusion of the proximal left anterior descending (LAD) artery, 90% stenosis of the left circumflex (LCx) artery, and Rentrop grade 3 collateral flow from a codominant right coronary artery. Due to financial constraints, revascularization was deferred. The patient was managed with high-intensity statins, dual antiplatelet therapy, beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, and lifestyle modification. Over follow-up, he showed marked symptomatic improvement, enhanced left ventricular ejection fraction, and partial reversal of diastolic dysfunction. This case highlights the importance of Lp(a) screening in premature CAD and demonstrates that intensive medical therapy can stabilize high-risk patients when revascularization is not feasible.