The Other “Bad” Cholesterol: Lp(a)

When we look at our cholesterol profile, we usually focus our attention on the “bad” cholesterol particle, the LDL.  About 20-30% of individuals have elevated levels of another cholesterol particle, the Lipoprotein(a) also called Lp(a) - a relative of the LDL particle – which puts those individuals at increased risk of having heart disease including plaque formation, heart attack and aortic valve stenosis.   Elevated elevates of Lp(a) may increase risk of heart disease by 2 to 3 times compared to those with normal levels.  An elevated level of Lp(a) is genetic, meaning it is inherited from one or both of your parents and the level is not significantly influenced by diet. 

Who should check their Lp(a) level?

Everyone should have an Lp(a) checked at least once in their life, at the time of a cardiac evaluation or evaluation of cholesterol profile, especially individuals with a strong family history of heart disease including heart attack or plaque build up in their arteries.  Additionally, if a first degree relative has an elevated Lp(a) level, you should have your level checked as well. If your Lp(a) level is normal it is unlikely that it needs to be checked again, as a normal Lp(a) level suggests that you have not inherited the genes that cause an elevated level.  If it is elevated, it is unclear if it should be checked regularly.

The American Heart Association recommends testing Lp(a) in individuals with borderline or intermediate risk of heart disease as well as those with a family history of premature coronary artery disease.

Why is the Lp(a) associated with a higher risk of heart disease?

The Lp(a) particle is essentially an LDL particle with an additional protein attached to it called apolipoprotein(a), and that additional protein increases the risk of heart attack through a number of ways.  Lp(a) can increase the risk of forming a clot, promote inflammation and formation of plaque in the arteries.

What can I do about an elevated Lp(a)?

The presence of an elevated Lp(a) value (greater than 125 nmol/L or 50 mg/dL) increases the risk of heart disease including heart attack.  It is unclear if taking medications that lower Lp(a) will lower your risk of heart disease.  Medications such as niacin and PCSK9 inhibitors(such as evolocumab aka Repatha) do lower Lp(a) but a reduction in risk of heart attack has not been demonstrated in those patients specifically.  Apheresis is a procedure that can filter Lp(a) from your blood, reducing levels up to 50%, but is a significant burden as it required regular treatments. There are a number of medications in clinical trials specifically targeting lowering Lp(a), which will potentially provide a therapy for reducing heart disease risk in patients with high Lp(a) levels.

In the meantime, aggressively lowering modifiable risk factors remains the focus of cardiac disease risk reduction in patients with Lp(a) including aggressively lowering LDL, managing blood sugar, avoidance of tobacco, optimizing diet (such as Mediterranean diet), regular dental cleanings and treating any inflammatory conditions. 

There may be a role for aspirin for reducing the risk of heart attack in those with Lp(a), but the decision to start aspirin should be discussed with a licensed provider.

All questions and concerns regarding Lp(a) and treatment should be discussed with a licensed provider.  The information found here is educational only and is not meant as a consultation or a substitute for a consultation with your doctor.