What is Lp(a) and is there anything I can do about it?
Lp(a) is a hereditary risk factor for cardiovascular disease that is independent of your LDL. Effective treatments are still largely lacking, but promising new drugs are on the way.
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.
Claims are based on multiple large epidemiological and genetic studies (including FOURIER with 25,096 patients), consensus documents and guidelines (PMIDs 39278229, 36036785, 39216091, 34647487, 33257928, 30586750, 37506332). RNA-based drugs have only been studied in phase 2 and early phase 3; endpoint studies are still ongoing.
How do you lower an elevated ApoB?
The most effective way to lower ApoB is with PCSK9 inhibitors (alirocumab or inclisiran, by prescription). Daily porridge also helps, but the effect is modest.
How does too much LDL or ApoB lead to clogged arteries?
Too many LDL and apoB particles sets off a well-established chain reaction that gradually clogs arteries. Having your apoB level measured gives your doctor a more accurate picture of your true risk than LDL cholesterol alone.
What is a healthy HDL (good cholesterol) level, and can I raise it?
Raising HDL through lifestyle is possible, but your genes set the ceiling. Lowering triglycerides through less sugar and alcohol, more exercise, and weight reduction has the greatest effect.
Who should have their ApoB measured?
Measuring ApoB is worthwhile for more people than current guidelines suggest: not only in cases of elevated blood fats, but also with excess weight, diabetes, familial hypercholesterolaemia, women after menopause, and people already taking cholesterol-lowering medication.
Is ApoB more important than regular cholesterol (LDL)?
ApoB consistently predicts cardiovascular disease better than LDL cholesterol. If you want to know how high your risk truly is, ask your doctor to measure ApoB alongside the standard cholesterol panel.
Is atrial fibrillation dangerous, and what can I do about it?
Atrial fibrillation substantially increases your risk of death, heart failure, and stroke, and requires active treatment. Discuss blood thinners for stroke prevention with your doctor, as well as which lifestyle changes are worthwhile in your specific situation.