Lipoprotein(a) Elevation: A New Diagnostic Code with Relevance to Service Members and Veterans

Cardiovascular disease (CVD) remains the leading cause of global mortality. In 2015, 41.5% of the US population had at least 1 form of CVD and CVD accounted for nearly 18 million deaths worldwide.1,2 The major disease categories represented include myocardial infarction (MI), sudden death, strokes, calcific aortic valve stenosis (CAVS), and peripheral vascular disease. ^1,2 In terms of health care costs, quality of life, and caregiver burden, the overall impact of disease prevalence continues to rise. ^1,3-6 There is an urgent need for more precise and earlier CVD risk assessment to guide lifestyle and therapeutic interventions for prevention of disease progression as well as potential reversal of preclinical disease. Even at a young age, visible coronary atherosclerosis has been found in up to 11% of “healthy” active individuals during autopsies for trauma fatalities. ^7,8

The impact of CVD on the US and global populations is profound. In 2011, CVD prevalence was predicted to reach 40% by 2030.9 That estimate was exceeded in 2015, and it is now predicted that by 2035, 45% of the US population will suffer from some form of clinical or preclinical CVD. In 2015, the decadeslong decline in CVD mortality was reversed for the first time since 1969, showing a 1% increase in deaths from CVD. ¹ Nearly 300,000 of those using US Department of Veterans Affairs (VA) services were hospitalized for CVD between 2010 and 2014. ¹⁰ The annual direct and indirect costs related to CVD in the US are estimated at $329.7 billion, and these costs are predicted to top $1 trillion by 2035. ¹ Heart attack, coronary atherosclerosis, and stroke accounted for 3 of the 10 most expensive conditions treated in US hospitals in 2013. ¹¹ Globally, the estimate for CVD-related direct and indirect costs was $863 billion in 2010 and may exceed $1 trillion by 2030. ¹²

The nature of military service adds additional risk factors, such as posttraumatic stress disorder, depression, sleep disorders and physical trauma which increase CVD morbidity/ mortality in service members, veterans, and their families. ^13-16 In addition, living in lowerincome areas (countries or neighborhoods) can increase the risk of both CVD incidence and fatalities, particularly in younger individuals. ^17-20 The Military Health System (MHS) and VA are responsible for the care of those individuals who have voluntarily taken on these additional risks through their time in service. This responsibility calls for rapid translation to practice tools and resources that can support interventions to minimize as many modifiable risk factors as possible and improve longterm health. This strategy aligns with the World Health Organization’s (WHO) focus on prevention of disease progression through interventions targeting modifiable risk. ^3-6,21-23 The driving force behind the launch of the US Department of Health and Human Services (HHS) Million Hearts program was the goal of preventing 1 million heart attacks and strokes by 2017 with risk reduction through aspirin, blood pressure control, cholesterol management, smoking cessation, sodium reduction, and physical activity. ^24,25 While some reductions in CVD events have been documented, the outcomes fell short of the goals set, highlighting both the need and value of continued and expanded efforts for CVD risk reduction. ²⁶