A 61-year-old man presented to his primary care physician for a routine physical examination. He was taking 25 mg of captopril (Capoten) twice daily for the treatment of hypertension, which had been diagnosed 5 years earlier. He did not smoke and had a normal body mass index. His mother had a myocardial infarction (MI) at 66 years of age.

The patient's lipid values were as follows: total cholesterol, 208 mg/dL; low-density lipoprotein (LDL) cholesterol, 132 mg/dL; high-density lipoprotein cholesterol, 54 mg/dL; triglycerides, 114 mg/dL; and lipoprotein(a), 123 mg/dL. A plasma glucose measurement excluded diabetes mellitus. The patient's urine was free of protein, and plasma creatinine values were normal. His blood pressure was 135/80 mm Hg.

The patient's hypertension and increased total and LDL cholesterol levels alone did not predict a very high risk of ischemic cardiovascular disease; however, his highly elevated lipoprotein(a) level placed him in the top 5% of the lipoprotein(a) distribution, which predicted a 3- to 4-fold increased risk of MI compared with that of an individual with lipoprotein(a) levels <5 mg/dL (<22nd percentile). Furthermore, considering his sex, age, and (treated) hypertension, together with his highly elevated lipoprotein(a) level, he was estimated to have a >20% risk of experiencing an MI within the next 10 years.

The patient continued taking his antihypertensive medication and also started treatment with 40 mg of atorvastatin (Lipitor) daily, which reduced his total cholesterol level to 125 mg/dL and LDL cholesterol level to 66 mg/dL, but did not affect his lipoprotein(a) level. The statin was well-tolerated, with no elevation of the alanine aminotransferase level or associated muscle pain. Substantial cholesterol reductions in hypercholesterolemic patients have been shown to reduce the influence of lipoprotein(a) in causing ischemic heart disease; hopefully, our patient's treatment will prevent him from experiencing an MI in the future. Adding nicotinic acid to his lipid-lowering treatment was considered because it reduces lipo-protein(a) as well as cholesterol and triglyceride levels.