We’ve all heard the story about starfish on the beach, a parable dripping with pathos about a boy who keeps throwing dried-out starfish back into the ocean to save a few of them from inevitable death.  Despite the harsh reality that, “there are thousands that he will never save,” he dutifully continues his altruistic endeavor, because “It mattered to that one.” (I was actually telling this story once at a national meeting and the microphone was ripped out of my hand mid-story.  Admittedly, I was a bit salty at first.  But since I don’t eat Hot Grudge Sundaes because those make you sick with bitterness, I’m not mad.  But I don’t forget…it mattered to this one, homie).

And the Starfish Story may even have some relevance when it comes to the discussion of folks with high Lp(a) and a CAC of zero.  In a recent analysis from the MESA multicohort study, in those with CAC of zero and high Lp(a) levels >50 mg/dL, there was a statistically significant 28% increased risk of having a cardiovascular event over the 14.8 year follow-up period. 

However, the absolute difference among people with CAC of zero with high Lp(a) vs people with CAC of zero with lower Lp(a) was 4.9 events per 1000 patient years vs 3.8 events per 1000 patient years.  This means that if 100 people were followed for 10 years with CAC of zero, there would be 1 more cardiovascular event if your Lp(a) is high vs if your Lp(a) was lower.  Put this way, “28% greater risk” doesn’t sound quite as scary.  Conversely, people with CAC>0 and high Lp(a) have a ~300% greater risk of having an event over the same time frame compared to those with CAC >0 and lower Lp(a) levels!  Once there’s been a break-in (positive CAC score), the Lp(a) Felons of the Lipid Neighborhood tend to be quite problematic!

So should we throw all the starfish with high Lp(a) back into the ocean regardless of CAC score?  I think that we need to check Lp(a) and CAC in all the starfish and then have a conversation between the clinician and the starfish patient about possible options.  And I think ascertaining a detailed family history is critical for both patients and echinoderms alike; people with high Lp(a) and no family history are probably in better shape than those whose Family Tree is riddled with premature coronary disease.  And, regardless of Lp(a) levels, we need to diligently assess the state of each person’s Metabolic Home Security System.

Some starfish can likely survive and thrive on the beach.  Others may need a helping hand to return to safer waters.  And as clinicians, it’s important we do our best to find that one starfish that, even with the low absolute risk of events having a CAC of zero, might need additional intervention.  Because “It matters to that one.”