Emerging implications of elevated lipoprotein(a) levels in coronary artery bypass graft surgery: a narrative review

<p dir="ltr"><b>Background:</b> Coronary artery bypass grafting (CABG) remains a cornerstone in the management of coronary artery disease (CAD). In nonurgent surgical revascularization cases, preoperative optimization of modifiable risk factors can improve outcomes. There is increasing interest in the relationship between lipoprotein(a) levels and the risk for ischemic cardiovascular disease, particularly how CABG outcomes are in turn affected. This review highlights the role of lipoprotein(a) in the pathogenesis of CAD and CABG outcomes and discusses future directions for its optimal management in the perioperative period. <p dir="ltr"><b>Methods:</b> The PubMed/MEDLINE database was reviewed until March 2024 to capture publications that evaluated and/or described the relationship between lipoprotein(a) and CABG surgery or CAD outcomes. <p dir="ltr"><b>Results:</b> The available literature supports lipoprotein(a) as a causal and independent risk factor for the pathogenesis of CAD. Elevated lipoprotein(a) levels are associated with an increased risk of adverse post-CABG outcomes, including graft occlusion incidence and major adverse cardiovascular events. Genetic variations influencing lipoprotein(a) levels play a role in disease progression and surgical outcomes. Several therapies aimed at reducing lipoprotein(a) levels, currently in phase III clinical trials, show promise for improving the prognosis after CABG. <p dir="ltr"><b>Conclusions:</b> Among individuals undergoing surgical revascularization for CAD, lipoprotein(a) levels may help define risk and inform best practices for perioperative management. We advocate for the routine measurement of lipoprotein(a) in all patients undergoing CABG. Emerging lipoprotein(a)-lowering agents show promise for secondary prevention of cardiac events, although dedicated analyses in cardiac surgical subcohorts will be important to evaluate their role in improving CABG outcomes.