Dr. Nguyen Tuan Long, Department of Cardiology, stated that the patient had an acute non-ST elevation myocardial infarction (NSTEMI). A coronary angiogram revealed a 95% narrowing in the right coronary artery (RCA3) segment. The patient underwent emergency stent placement to restore blood flow to the heart muscle.

Mr. Tung has a history of hypertension, diabetes, chronic kidney disease stage 3B, and peripheral artery disease. In 4/2024, he suffered a myocardial infarction and had stents placed in his right coronary artery and circumflex artery at another hospital. Following the intervention, he adhered to his medication regimen and attended regular follow-up appointments.

Before this recent event, Mr. Tung had well-controlled cardiovascular risk factors. His blood pressure remained below 130/80 mmHg, blood sugar was stable, and LDL cholesterol (bad cholesterol) was at 1,16 mmol/L. He did not smoke, maintained a normal body mass index (BMI), and fully complied with his treatment.

According to Dr. Long, patients who have previously experienced a myocardial infarction and received stents still face a risk of recurrence. This is because atherosclerosis is a chronic disease that can continue to progress over time. However, with Mr. Tung's well-controlled blood pressure, blood sugar, and blood lipids, his risk of recurrence should have been significantly reduced.

The coronary angiogram showed that the previously placed stents remained patent, with no significant restenosis. However, new atherosclerotic lesions appeared in the left main coronary artery and the distal right coronary artery, or existing plaques progressed rapidly. Therefore, doctors suspected that the patient's recurrent myocardial infarction was due to "residual cardiovascular risk".

A detailed assessment revealed that despite achieving the target LDL cholesterol level, the patient's lipoprotein(a) - Lp(a) level remained elevated at 176 nmol/L. According to Dr. Long, Lp(a) is a genetically determined lipoprotein considered an independent risk factor for cardiovascular disease, as it promotes plaque formation and blood clots.

Unlike LDL cholesterol, which is significantly influenced by diet, exercise, and medication, Lp(a) levels are primarily determined by genetic factors and remain relatively stable throughout life. Consequently, many individuals can have high Lp(a) despite maintaining a healthy lifestyle and effectively controlling conventional lipid levels.

The team performed emergency intervention for the patient's myocardial infarction. Photo: Tam Anh General Hospital

Given the patient's diabetes, chronic kidney disease stage 3B, and multi-vessel atherosclerosis, doctors carefully considered the use of antithrombotic medications to balance the effectiveness of preventing myocardial infarction with the risk of bleeding.

Mr. Tung needs a follow-up visit in 4-6 weeks to re-evaluate the effectiveness of lipid control, including LDL and ApoB, which reflects the total number of atherogenic lipoprotein particles. Concurrently, doctors will monitor other residual cardiovascular risk factors to adjust the treatment regimen as needed.

According to Dr. Long, there are currently no methods to change Lp(a) levels through diet or exercise. Therefore, for individuals with elevated Lp(a), the treatment goal is to more tightly control other cardiovascular risk factors, particularly bringing LDL-C to recommended levels, while aggressively treating co-existing medical conditions. International cardiovascular guidelines recommend that adults undergo Lp(a) testing at least once, especially if they have atherosclerotic cardiovascular disease, a family history of early cardiovascular disease, or suspected hereditary dyslipidemia.

Stent placement for myocardial infarction only addresses the narrowed or blocked segment of the artery at the time of intervention. The atherosclerotic process continues to progress, potentially causing narrowing or blockage in other arterial segments if long-term cardiovascular risk factors are not well controlled. Therefore, patients must attend scheduled follow-ups, maintain prescribed medications, and effectively control blood pressure, blood sugar, blood lipids, weight, diet, and exercise. Depending on the risk level and individual patient characteristics, doctors will further assess residual cardiovascular risk factors to individualize treatment.

Ly Nguyen

*Patient's name has been changed.