Premature Coronary Artery Disease in a Young Female Patient With High Lipoprotein(a)

BACKGROUND: Premature coronary artery disease (CAD) poses diagnostic challenges, particularly in patients with minimal traditional risk factors. High lipoprotein(a) [Lp(a)] is an independent, genetically determined risk factor for atherosclerotic cardiovascular disease, and it contributes to early and progressive CAD. CASE SUMMARY: We report the case of a 35-year-old African American woman with recurrent chest pain who was diagnosed with severe multivessel CAD despite minimal traditional cardiovascular risk factors. Further evaluation revealed markedly high Lp(a) levels. She underwent successful percutaneous coronary intervention and achieved optimal low-density lipoprotein cholesterol (LDL-C) control with high-intensity statin therapy and a PCSK9 inhibitor. Despite aggressive lipid-lowering therapy, she developed recurrent angina within 6 months, and repeat coronary angiography demonstrated disease progression. DISCUSSION: This case highlights the role of high Lp(a) in driving premature and progressive CAD independent of LDL-C levels. Early identification of high Lp(a) may improve risk stratification and inform management strategies. TAKE-HOME MESSAGE: High Lp(a) may contribute to premature and progressive CAD even with optimal LDL-C control, supporting consideration of Lp(a) testing in young patients with unexplained or familial CAD.