Editorial: Impact of elevated lipoprotein(a) on epicardial coronary flow conductance and endoluminal atherosclerotic disease distribution
Elevated lipoprotein(a) levels have long been associated with a heightened risk of cardiovascular events. Imaging studies have determined elevated Lp(a) to be correlated with increased plaque progression, greater atheroma volume, and the development of vulnerable plaque features [
[1],
[2],
[3]]. Several studies have further suggested that patients with elevated Lp(a) are more likely to develop diffuse and widespread atherosclerosis, rather than distinct focal lesions, supporting the notion that Lp(a) may contribute to a unique multivessel phenotype of CAD [
[4],
[5],
[6]].
To date, these observations have remained largely confined to the anatomic domain, with limited understanding of how Lp(a)-driven atherosclerosis impacts coronary physiology. As the presence of plaque alone does not necessarily explain symptoms or define flow-limiting stenosis. Fractional flow reserve (FFR) has emerged as an essential tool clinical practice by enabling the identification of hemodynamically significant disease and guiding revascularization strategies. In this context, the study by Renkens et al. represents a novel step forward, directly linking Lp(a)-related plaque biology with coronary flow dynamics [
7].
In a propensity-matched analysis from the PIONEER IV PCI trial, Renkens et al. applied quantitative flow ratio (QFR) and the QFR–Pressure Pullback Gradient Index (QFR-PPGi) to characterize coronary physiology. QFR, which has been validated against FFR, reconstructs a three-dimensional model of the coronary artery from angiography and applies computational flow dynamics to non-invasively estimate pressure loss across a vessel [
8]. The present study found that patients with elevated Lp(a) demonstrated lower QFR values, a higher prevalence of flow limiting stenoses, and reduced PPGi scores, findings consistent with a more diffuse and obstructive epicardial disease pattern as compared to those with normal Lp(a) levels.