Most people are familiar with the concept of “good” and “bad” cholesterol, but few have heard of lipoprotein(a), often abbreviated as Lp(a). This lesser-known cholesterol particle is gaining significant attention from researchers and pharmaceutical companies due to its strong link to heart attacks and strokes, even in individuals who maintain otherwise healthy lifestyles.
What Is Lipoprotein(a)?
Lipoprotein(a) is a type of cholesterol that carries lipoproteins—particles composed of fats and proteins—through the bloodstream. Structurally, it resembles LDL, or “bad” cholesterol, but it has an additional protein called apolipoprotein(a) attached. This extra component makes Lp(a) more prone to contributing to fatty deposit buildup in arteries and may also promote blood clotting. Together, these processes increase the likelihood of cardiovascular disease, including heart attacks and strokes. Large-scale studies and international guidelines now recognise Lp(a) as a significant risk factor for these conditions.
What Determines Your Lp(a) Levels?
Unlike most cholesterol measures, Lp(a) levels are largely determined by genetics. Approximately 70% to 90% of the variation in Lp(a) levels is inherited, primarily driven by differences in the LPA gene, which controls the structure of apolipoprotein(a). Because of this strong genetic control, Lp(a) levels are typically set early in life and remain relatively stable over time, with little influence from diet, exercise, or body weight. Some smaller influences exist, such as sex, ethnicity, hormonal changes, and conditions like menopause or kidney disease, but these have only minor effects.
How Does Lp(a) Affect Your Risk?
A growing body of research shows that higher Lp(a) levels are associated with an increased risk of heart attacks, strokes, and aortic valve disease. Importantly, the relationship appears continuous: cardiovascular risk rises step by step as Lp(a) levels increase. Lp(a) also adds to overall risk when combined with other factors. For example, someone with both high LDL cholesterol and high Lp(a) is likely to face a higher risk than someone with elevated LDL cholesterol alone. For individuals with higher Lp(a) levels, cardiovascular risk rises primarily when inflammation is elevated. This helps explain why some people develop cardiovascular disease despite otherwise favourable risk profiles.
Can You Lower Lipoprotein(a)?
Currently, there are few options to lower Lp(a) directly. Lifestyle changes that improve heart health, such as eating well, being physically active, and not smoking, remain essential but have minimal effect on Lp(a) itself. Most commonly used cholesterol-lowering medications, including statins, do not reduce Lp(a); in some cases, statins may even increase Lp(a) slightly. Despite this, statins still reduce overall cardiovascular risk and remain a cornerstone of treatment. Some newer drugs, such as PCSK9 inhibitors, can lower Lp(a) by a modest 15% to 30%.
However, several pharmaceutical companies, including Novartis, Amgen, and Eli Lilly, are racing to develop treatments that specifically target Lp(a). These new medicines work differently from statins. Instead of helping the body clear cholesterol from the blood, they use a “gene silencing” approach that reduces how much Lp(a) the liver produces. In early clinical trials, these drugs have lowered Lp(a) levels by 80% to 90%, far exceeding existing treatments. If upcoming trials show that these large reductions lead to fewer heart attacks and strokes, it could change how cardiovascular risk is assessed and treated, especially for people whose risk is driven largely by genetics rather than lifestyle.
Should You Get Tested?
Lp(a) is not included in standard cholesterol tests; a specific blood test is required. In many healthcare systems, this test is not covered by insurance, so patients may have to pay out of pocket. International guidelines now recommend measuring Lp(a) at least once in adulthood, particularly for individuals with a family history of early heart disease or unexplained cardiovascular risk. Because levels are largely genetically determined and stable, a single measurement is often considered sufficient for most people.
What Should You Focus On?
Learning that you have high Lp(a) can be frustrating, given the limited options to lower it directly. However, it is important to see Lp(a) as one part of your overall cardiovascular risk. There are still many factors you can influence to lower your overall risk, particularly your LDL cholesterol. These include managing LDL cholesterol, blood pressure, smoking, physical activity, diet quality, and conditions such as diabetes. For people with elevated Lp(a), managing these factors may be even more important.
What Happens Next?
Research into Lp(a) is moving quickly. If current clinical trials show that targeted therapies reduce cardiovascular events, testing and treatment may become more common. For now, awareness is an important first step. If you are concerned about your cardiovascular risk, it may be worth discussing Lp(a) testing with your doctor, especially if you have a strong family history of heart disease. At the same time, the broader message to maximise heart health through healthy behaviours remains unchanged. Even as new risk factors emerge, the foundations of good heart health are still the things we can control.
