Lipoprotein (a) as a cause of premature coronary artery disease; a case report of a 34-year-old male patient presenting with ST elevation myocardial infarction.

Background Premature coronary artery disease (PCAD) is considered when coronary artery disease (CAD) occurs in the younger population, less than 45 years old in males. Modifiable risk factors are present in about 80% of patients with PCAD such as smoking, diabetes, high blood pressure and obesity. High serum lipoprotein (a) level has recently emerged as a risk factor for PCAD. However, it is not routinely investigated in young patients presenting with acute coronary syndromes. Case Presentation A 34-year-old African man presented to our hospital with 2 hours of worsening left sided chest pain. He gave a history of long-standing chest pain in the past that was being managed as peptic ulcer disease. He also complained of a slow heart rate. He had no traditional cardiovascular risk factors. The only significant history was a recent recovery from COVID-19 infection two months prior. His physical examination was only significant for a bradycardia, ECG revealed a hyper acute inferior STEMI without right ventricular involvement. Echo showed a normal left ventricle with reduced ejection fraction (EF: 50%), wall motion abnormalities consistent of an inferior MI. He immediately received streptokinase with good clinical and ECG response. His coronary angiogram showed a severe lesion and plaque rupture in the mid-distal segment of a dominant right coronary artery. Percutaneous coronary intervention (PCI) was successfully done, and one drug eluting stent was implanted. He was placed on guideline directed medical therapy for secondary prevention. The only significant possible aetiology found was an elevated Lipoprotein (a) (137mg/dl). Subsequent serum Lipoprotein (a) remained persistently elevated despite therapy with high dose niacin. He was recommended for a PCSK9 receptor blocker, but this medication is not available in the country and the patient could not meet the costs. He remains stable to current medications with no recurrence of chest pain, two years after the index event, the Lipoprotein (a) levels are still high. Conclusions: Lipoprotein (a) appears to be an important overlooked cardiovascular risk factor for premature coronary artery disease especially in the absence of traditional risk factors. It should always be considered in the screening of premature coronary cardiovascular disease. The acute presentation in this patient was probably triggered by SARS COV-2 infection.