What is Lp(a) and is there anything I can do about it?

Lp(a) is a fat particle in your blood, similar to LDL cholesterol but with an extra protein attached to it. It raises your risk of cardiovascular disease and of calcification of the aortic valve. Large studies involving hundreds of thousands of people have shown that this relationship is causal: a high Lp(a) genuinely causes damage. Women with the highest levels had a 33% greater chance of a serious cardiovascular event over thirty years compared with women with the lowest levels.

Lp(a) is also dangerous when your LDL is already low. Even with well-controlled LDL, a high Lp(a) still increases your risk. This is because 70 to more than 90% of your Lp(a) level is genetically determined. Lifestyle and diet barely change it. Approximately one in five people worldwide has an elevated level. People of African descent have on average the highest levels; women after menopause are on average 17% higher than men.

What can you do about it? Unfortunately, very little through lifestyle. Statins, the most commonly used cholesterol-lowering drugs, do not work against Lp(a). Newer injectable cholesterol-lowering drugs, known as PCSK9 inhibitors, lower Lp(a) by an average of around 27%. That is measurable but modest. Whether that reduction actually leads to fewer cardiovascular problems remains uncertain; the result was not statistically significant in studies.

For an extremely high Lp(a) combined with persistent cardiovascular disease despite all medications, blood filtration exists as an option. This mechanically removes Lp(a), but the supporting evidence is limited. More promising are new RNA-based drugs, such as pelacarsen and olpasiran. These lower Lp(a) by 65 to 98% in human studies, but they have not yet been approved. The large studies that must demonstrate whether this actually results in fewer heart attacks and strokes are still ongoing.

Practical advice from multiple guidelines: have Lp(a) measured at least once, especially with an elevated cardiovascular risk, a family history of cardiovascular disease, or hereditary high cholesterol. Because the level is so strongly genetically determined, it barely changes over the course of your life. In principle, one measurement is therefore sufficient. There are also preliminary indications that a very low Lp(a) may be associated with a slightly higher diabetes risk, but this is uncertain and requires further research.