Researcher Q&A: Advancing health science to improve heart attack and stroke prevention

Every 34 seconds in the United States, someone has a heart attack. And approximately every minute, heart disease claims a life. Because heart disease is the leading cause of mortality in America – and only growing in prevalence worldwide – leading researchers are dedicated to developing better preventive treatments. For patients who have experienced a heart attack or stroke, predisposing them to subsequent events, these efforts are especially critical.

To learn more, we sat down with Dr. Svati Shah, director of the Duke Adult Cardiovascular Genetics Clinic. Many of her patients have experienced cardiac events, and helping reduce the risk of recurrence is an important part of her practice. Now, Dr. Shah shares her path toward caring for patients with heart-related genetic disorders, and the promise of new research.

Tell us about your background. What drew you to cardiology and genetics?

My passion for research was sparked in college, and I actually studied public health before I went to medical school because I wanted to learn how to do good research. When I was in training to become a cardiologist, I was shocked at how many patients were having heart attacks at an early age, and how your family history had a very strong influence on that. Since then, I have been researching genetic and other risk factors for heart attacks, and I take care of patients who have genetic heart disorders. It's very inspiring work because patients want to know why they have heart disease – and, often more importantly to them, how to reduce risk for their family members.

How did you get involved with Project Baseline?

As a scientist and doctor, my focus is on genetics, disease prevention, and getting more predictive about health. I wanted to help break new ground on human health through a study that was the first of its kind: the Project Baseline Health Study. As a longitudinal study focused on gathering complex health data from diverse patients nationwide, the Health Study was unique. I became a principal investigator on the Health Study in 2017, and because of my cardiology background, partnering on the Heart Biomarker Study was a natural progression.

The Heart Biomarker Study is an effort to better understand lipoprotein(a), a genetic risk factor for heart disease. Along with my work on the study, I also have a laboratory within the Duke Molecular Physiology Institute that uses new technologies to study DNA and molecules circulating in the blood.

Studying an individual's unique footprint of blood particles can reveal what diseases they may be predisposed to, and how best to treat them – far more detailed information than we would typically learn during a medical appointment. Lipoprotein(a), or Lp(a), is one of these molecules. I believe strongly that exploring heart disease through the Heart Biomarker Study can help move precision medicine and personalized care forward.

On that note, what is Lp(a)? Why is understanding it better so important?

Lp(a) (pronounced L-P-little-A) is a type of cholesterol that circulates in the blood and is not specifically measured by traditional cholesterol tests. Having high Lp(a) levels doubles your risk of having a first heart attack, and also increases your risk of having another heart attack or stroke. In fact, patients who have treated LDL cholesterol levels (the regularly measured "bad" cholesterol) but who have elevated Lp(a) levels are at increased risk of having another heart attack or stroke.

Can you speak to genetics and risk as it relates to Lp(a)? If we know that high Lp(a) is associated with heart attacks, why do we need more research?

Lp(a) levels are almost completely determined by genetics. In fact, Lp(a) levels are actually controlled by a single gene. While it's established that Lp(a) is genetic, and high Lp(a) increases your heart disease risk, we need to know more. Specifically, we need to know if lowering Lp(a) levels actually leads to better cardiovascular outcomes, and when we should initiate Lp(a) lowering drugs. It's an exciting area of cardiovascular research and shows promise in helping heart patients.

Is there anything people with elevated Lp(a) can do to lower it today?

While diet and exercise are very important things for patients to do to prevent heart disease through other mechanisms, unfortunately, they do not work well for reducing Lp(a) levels. Some of the newer cholesterol medications have been shown to lower Lp(a) levels, but do not specifically target the Lp(a) particle.

Talk to us a bit about the study design. Why is this research focused on heart attack and stroke survivors?

Unfortunately, recurrent cardiovascular events are common in patients. This is due to many factors and we know some of the risk factors that lead to this, but for a given patient, it's hard to predict with certainty what their risk is. This study will measure Lp(a) levels in patients who have already suffered a heart attack or stroke and try to understand how a patient's knowing their Lp(a) levels might change their perception of their future risk.

The Heart Biomarker Study's goal is advancing science to reduce heart attacks and strokes. For patients who have already had a heart attack or stroke, we need to understand what role new risk factors may play. The Heart Biomarker Study gets us closer, but we can't do it without patients: they hold the key.

Not many heart patients are aware of their Lp(a) level today, so we're also looking at how lifestyle or therapeutic choices may change once a patient's Lp(a) level is known. Gaining insight into these questions is critical to improving heart patient care.

If you've experienced a heart attack or stroke, you may be eligible to join the Heart Biomarker Study. Learn more and consider getting involved.